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Andersson C, Kawuki T, Månsson J, Nankaja C, Sund K, Wigren E, Zungu MM. The impact of a reproductive health voucher in Uganda using a quasi-experimental matching design. Reprod Health 2024; 21:82. [PMID: 38849864 PMCID: PMC11157895 DOI: 10.1186/s12978-024-01812-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 05/08/2024] [Indexed: 06/09/2024] Open
Abstract
This study assesses the impact of a voucher project that targeted vulnerable and poor pregnant women in Uganda. Highly subsidised vouchers gave access to a package of safe delivery services consisting of four antenatal visits, safe delivery, one postnatal visit, the treatment and management of selected pregnancy-related medical conditions and complications, and emergency transport. Vouchers were sold during the project's operational period from 2016 to 2019. This study covers 8 out of 25 project-benefiting districts in Uganda and a total of 1,881 pregnancies, including both beneficiary and non-beneficiary mothers. Using a matching design, the results show a positive effect on the survival of new-born babies. The difference in the survival rate between the control group and the treatment group is 5.4% points, indicating that the voucher project reduced infant mortality by more than 65 per cent.
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Affiliation(s)
- Christian Andersson
- The Swedish National Audit Office, Stockholm, 102 33, Sweden
- Blekinge Institute of Technology, Karlskrona, 371 41, Sweden
| | - Tonny Kawuki
- The Office of the Auditor General Uganda, Kampala, Uganda
| | - Jonas Månsson
- Blekinge Institute of Technology, Karlskrona, 371 41, Sweden.
| | | | - Krister Sund
- The Swedish National Audit Office, Stockholm, 102 33, Sweden
- The Swedish Institute for Social Research, Stockholm, 106 91, Sweden
| | - Emma Wigren
- The Swedish National Audit Office, Stockholm, 102 33, Sweden
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2
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Sáenz R, Nigenda G, Gómez-Duarte I, Rojas K, Castro A, Serván-Mori E. Persistent inequities in maternal mortality in Latin America and the Caribbean, 1990-2019. Int J Equity Health 2024; 23:96. [PMID: 38730305 PMCID: PMC11088099 DOI: 10.1186/s12939-024-02100-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 01/09/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Despite the resources and personnel mobilized in Latin America and the Caribbean to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 live births) in women aged 10-54 years by 75% between 2000 and 2015, the region failed to meet the Millenium Development Goals (MDGs) due to persistent barriers to access quality reproductive, maternal, and neonatal health services. METHODS Using 1990-2019 data from the Global Burden of Disease project, we carried out a two-stepwise analysis to (a) identify the differences in the MMR temporal patterns and (b) assess its relationship with selected indicators: government health expenditure (GHE), the GHE as percentage of gross domestic product (GDP), the availability of human resources for health (HRH), the coverage of effective interventions to reduce maternal mortality, and the level of economic development of each country. FINDINGS In the descriptive analysis, we observed a heterogeneous overall reduction of MMR in the region between 1990 and 2019 and heterogeneous overall increases in the GHE, GHE/GDP, and HRH availability. The correlation analysis showed a close, negative, and dependent association of the economic development level between the MMR and GHE per capita, the percentage of GHE to GDP, the availability of HRH, and the coverage of SBA. We observed the lowest MMRs when GHE as a percentage of GDP was close to 3% or about US$400 GHE per capita, HRH availability of 6 doctors, nurses, and midwives per 1,000 inhabitants, and skilled birth attendance levels above 90%. CONCLUSIONS Within the framework of the Sustainable Development Goals (SDGs) agenda, health policies aimed at the effective reduction of maternal mortality should consider allocating more resources as a necessary but not sufficient condition to achieve the goals and should prioritize the implementation of new forms of care with a gender and rights approach, as well as strengthening actions focused on vulnerable groups.
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Affiliation(s)
- Rocío Sáenz
- Center for Research in Nursing and Health Care (CICES), University of Costa Rica, San Pedro Montes de Oca, San Jose, Costa Rica
| | - Gustavo Nigenda
- Faculty of Nursing and Obstetrics, National Autonomous University of Mexico, Mexico City, Mexico
| | - Ingrid Gómez-Duarte
- Center for Research in Nursing and Health Care (CICES), University of Costa Rica, San Pedro Montes de Oca, San Jose, Costa Rica
| | - Karol Rojas
- Center for Research in Nursing and Health Care (CICES), University of Costa Rica, San Pedro Montes de Oca, San Jose, Costa Rica
| | - Arachu Castro
- Department of International Health and Sustainable Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, State of Louisiana, USA
| | - Edson Serván-Mori
- Center for Health Systems Research, National Institute of Public Health of Mexico, Universidad Av. 655, Cuernavaca, Morelos, Mexico.
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Moolla A, Mdewa W, Erzse A, Hofman K, Thsehla E, Goldstein S, Kohli-Lynch C. A cost-effectiveness analysis of a South African pregnancy support grant. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002781. [PMID: 38329926 PMCID: PMC10852248 DOI: 10.1371/journal.pgph.0002781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/14/2024] [Indexed: 02/10/2024]
Abstract
Poverty among expectant mothers often results in sub-optimal maternal nutrition and inadequate antenatal care, with negative consequences on child health outcomes. South Africa has a child support grant that is available from birth to those in need. This study aims to determine whether a pregnancy support grant, administered through the extension of the child support grant, would be cost-effective compared to the existing child support grant alone. A cost-utility analysis was performed using a decision-tree model to predict the incremental costs (ZAR) and disability-adjusted life years (DALYs) averted by the pregnancy support grant over a 2-year time horizon. An ingredients-based approach to costing was completed from a governmental perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were performed. The intervention resulted in a cost saving of R13.8 billion ($930 million, 95% CI: ZAR3.91 billion - ZAR23.2 billion/ $1.57 billion - $264 million) and averted 59,000 DALYs (95% CI: -6,400-110,000), indicating that the intervention is highly cost-effective. The primary cost driver was low birthweight requiring neonatal intensive care, with a disaggregated incremental cost of R31,800 ($2,149) per pregnancy. Mortality contributed most significantly to the DALYs accrued in the comparator (0.68 DALYs). The intervention remained the dominant strategy in the sensitivity analyses. The pregnancy support grant is a highly cost-effective solution for supporting expecting mothers and ensuring healthy pregnancies. With its positive impact on child health outcomes, there is a clear imperative for government to implement this grant. By investing in this program, cost savings could be leveraged. The implementation of this grant should be given high priority in public health and social policies.
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Affiliation(s)
- Aisha Moolla
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Winfrida Mdewa
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Evelyn Thsehla
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ciaran Kohli-Lynch
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
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McGuire F, Mohan S, Walker S, Nabyonga-Orem J, Ssengooba F, Kataika E, Revill P. Adapting Economic Evaluation Methods to Shifting Global Health Priorities: Assessing the Value of Health System Inputs. Value Health Reg Issues 2024; 39:31-39. [PMID: 37976775 DOI: 10.1016/j.vhri.2023.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/11/2023] [Accepted: 08/07/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES We highlight the importance of undertaking value assessments for health system inputs if allocative efficiency is to be achieve with health sector resources, with a focus on low- and middle-income countries. However, methodological challenges complicated the application of current economic evaluation techniques to health system input investments. METHODS We undertake a review of the literature to examine how assessments of investments in health system inputs have been considered to date, highlighting several studies that have suggested ways to address the methodological issues. Additionally, we surveyed how empirical economic evaluations of health system inputs have approached these issues. Finally, we highlight the steps required to move toward a comprehensive standardized framework for undertaking economic evaluations to make value assessments for investments in health systems. RESULTS Although the methodological challenges have been illustrated, a comprehensive framework for value assessments of health system inputs, guiding the evidence required, does not exist. The applied literature of economic evaluations of health system inputs has largely ignored the issues, likely resulting in inaccurate assessments of cost-effectiveness. CONCLUSIONS A majority of health sector budgets are spent on health system inputs, facilitating the provision of healthcare interventions. Although economic evaluation methods are a key component in priority setting for healthcare interventions, such methods are less commonly applied to decision making for investments in health system inputs. Given the growing agenda for investments in health systems, a framework will be increasingly required to guide governments and development partners in prioritizing investments in scarce health sector budgets.
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Affiliation(s)
- Finn McGuire
- Centre for Health Economics, University of York, York, England, UK.
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, England, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, England, UK
| | - Juliet Nabyonga-Orem
- Inter-Country Support Team for Eastern and Southern Africa, UHC Life Course Cluster, World Health Organization, Brazzaville, Republic of Congo; Centre for Health Professions Education, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Edward Kataika
- East, Central and Southern Africa Health Community, Arusha, Tanzania
| | - Paul Revill
- Centre for Health Economics, University of York, York, England, UK
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George J, Jack S, Gauld R, Colbourn T, Stokes T. Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review. BMJ Open 2023; 13:e073669. [PMID: 38081664 PMCID: PMC10729209 DOI: 10.1136/bmjopen-2023-073669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs. METHODS We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed. RESULTS The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation. CONCLUSIONS We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.
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Affiliation(s)
- Joby George
- Department of General Practice & Rural Health, University of Otago, Dunedin, New Zealand
| | - Susan Jack
- Te Whatu Ora - Southern, National Public Health Service, Dunedin, New Zealand
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
| | - Robin Gauld
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
- Otago Business School, University of Otago, Dunedin, New Zealand
| | | | - Tim Stokes
- Department of General Practice & Rural Health, University of Otago, Dunedin, New Zealand
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Dundas R, Boroujerdi M, Browne S, Deidda M, Bradshaw P, Craig P, McIntosh E, Parkes A, Wight D, Wright C, Leyland AH. Evaluation of the Healthy Start voucher scheme on maternal vitamin use and child breastfeeding: a natural experiment using data linkage. PUBLIC HEALTH RESEARCH 2023; 11:1-101. [PMID: 37953640 DOI: 10.3310/rteu2107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
Background Having a good start in life during pregnancy and infancy has been shown to be important for living both a healthy life and a longer life. Despite the introduction of many policies for the early-years age group, including voucher schemes, with the aim of improving nutrition, there is limited evidence of their impact on health. Objectives To assess the effectiveness of the Healthy Start voucher scheme on infant, child and maternal outcomes, and to capture the lived experiences of the Healthy Start voucher scheme for low-income women. Design This was a natural experiment study using existing data sets, linked to routinely collected health data sets, with a nested qualitative study of low-income women and an assessment of the health economics. Setting Representative sample of Scottish children and UK children. Participants Growing Up in Scotland cohort 2 (n = 2240), respondents to the 2015 Infant Feeding Study (n = 8067) and a sample of 40 participants in the qualitative study. Interventions The Health Start voucher, a means-tested scheme that provides vouchers worth £3.10 per week to spend on liquid milk, formula milk, fruit and vegetables. Main outcome measures Infant and child outcomes - breastfeeding initiation and duration; maternal outcomes - vitamin use pre and during pregnancy. Results The exposed group were women receiving the Healthy Start voucher (R), with two control groups: eligible and not claiming the Healthy Start voucher (E) and nearly eligible. There was no difference in vitamin use during pregnancy for either comparison (receiving the Healthy Start voucher, 82%; eligible and not claiming the Healthy Start voucher, 86%; p = 0.10 vs. receiving the Healthy Start voucher, 87%; nearly eligible, 88%; p = 0.43) in the Growing Up in Scotland cohort. Proportions were similar for the Infant Feeding Study cohort (receiving the Healthy Start voucher, 89%; eligible and not claiming the Healthy Start voucher, 86%; p = 0.01 vs. receiving the Healthy Start voucher, 89%; nearly eligible, 87%; p = 0.01); although results were statistically significantly different, these were small effect sizes. There was no difference for either comparison in breastfeeding initiation or breastfeeding duration in months in Growing Up in Scotland, but there was a negative effect of the Healthy Start voucher in the Infant Feeding Survey. This contrast between data sets indicates that results are inconclusive for breastfeeding. The qualitative study found that despite the low monetary value the women valued the Healthy Start voucher scheme. However, the broader lives of low-income women are crucial to understand the constraints to offer a healthy diet. Limitations Owing to the policy being in place, it was difficult to identify appropriate control groups using existing data sources, especially in the Infant Feeding Study. Conclusions As the Healthy Start voucher scheme attempts to influence health behaviour, this evaluation can inform other policies aiming to change behaviour and use voucher incentives. The null effect of Healthy Start vouchers on the primary outcomes may be due to the value of the vouchers being insufficient to change the broader lives of low-income women to offer a healthy diet. Future work The methods developed to undertake an economic evaluation alongside a natural experiment using existing data can be used to explore the cost-effectiveness of the Healthy Start voucher scheme. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ruth Dundas
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Massoud Boroujerdi
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Susan Browne
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Manuela Deidda
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | | | - Peter Craig
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Emma McIntosh
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | - Alison Parkes
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Daniel Wight
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Charlotte Wright
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Alastair H Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Serván-Mori E, Meneses-Navarro S, Garcia-Diaz R, Flamand L, Gómez-Dantés O, Lozano R. Inequitable Financial Protection in Health for Indigenous Populations: the Mexican Case. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01770-8. [PMID: 37697143 DOI: 10.1007/s40615-023-01770-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND There is an important gap in the literature concerning the level, inequality, and evolution of financial protection for indigenous (IH) and non-indigenous (NIH) households in low- and middle-income countries. This paper offers an assessment of the level, socioeconomic inequality and middle-term trends of catastrophic (CHE), impoverishing (IHE), and excessive (EHE) health expenditures in Mexican IHs and NIHs during the period 2008-2020. METHODS We conducted a pooled cross-sectional analysis using the last seven waves of the National Household Income and Expenditure Survey (n = 315,829 households). We assessed socioeconomic inequality in CHE, IHE, and EHE by estimating their Wagstaff concentration indices according to indigenous status. We adjusted the CHE, IHE, and EHE by estimating a maximum-likelihood two-stage probit model with robust standard errors. RESULTS We observed that, during the period analyzed, CHE, IHE, and EHE were concentrated in the poorest IHs. CHE decreased from 5.4% vs. 4.7% in 2008 to 3.4% vs. 2.9% in 2014 in IHs and NIHs, respectively, and converged at 2008 levels towards 2020. IHE remained unchanged from 2008 to 2014 (1.6% for IHs vs. 1.0% for NIHs) and increased by 40% in IHs and NIHs during 2016-2020. EHE plunged in 2014 (4.6% in IHs vs. 3.8% in NIHs), then rose, and remained unchanged during 2016-2020 (6.7% in IHs and 5.6% in NIHs). CONCLUSION In pursuit of universal health coverage, health authorities should formulate and implement effective financial protection mechanisms to address structural inequalities, especially forms of discrimination including racialization, that vulnerable social groups such as indigenous peoples have systematically faced. Doing so would contribute to closing the persistent ethnic gaps in health.
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Affiliation(s)
- Edson Serván-Mori
- Center for Health Systems Research, The National Institute of Public Health, Cuernavaca, Mexico
| | - Sergio Meneses-Navarro
- Center for Health Systems Research, The National Institute of Public Health, Cuernavaca, Mexico.
- The National Council of Humanities, Sciences and Technology, Del. Benito Juarez, Mexico.
| | - Rocio Garcia-Diaz
- Tecnologico de Monterrey, School of Social Science and Government, Monterrey, Nuevo Leon, Mexico
| | - Laura Flamand
- Center for International Studies, The College of Mexico, Mexico City, Mexico
| | - Octavio Gómez-Dantés
- Center for Health Systems Research, The National Institute of Public Health, Cuernavaca, Mexico
| | - Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA
- School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
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Mushasha R, El Bcheraoui C. Comparative effectiveness of financing models in development assistance for health and the role of results-based funding approaches: a scoping review. Global Health 2023; 19:39. [PMID: 37340310 DOI: 10.1186/s12992-023-00942-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/12/2023] [Indexed: 06/22/2023] Open
Abstract
Over the past three decades, there has been an unprecedented growth in development assistance for health through different financing models, ranging from donations to results-based approaches, to improve health in low- and middle-income countries. Since then, the global burden of disease has started to shift. However, it is still not entirely clear what the comparative effect of the different financing models is. To assess the effect of these financing models on various healthcare targets, we systematically reviewed the peer-reviewed and gray literature. We identified 19 studies and found that results-based financing approaches have an overall positive impact on institutional delivery rates and numbers of healthcare facility visits, though this impact varies greatly by context.Donors might be better served by providing a results-based financing scheme combining demand and supply side health-related schemes. It is essential to include rigorous monitoring and evaluation strategies when designing financing models.
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Affiliation(s)
- Rand Mushasha
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, Augustenburger Pl. 1, 13353, Berlin, Germany
- Evidence-Based Public Health, Centre for International Health Protection, Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany
| | - Charbel El Bcheraoui
- Evidence-Based Public Health, Centre for International Health Protection, Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany.
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Oskowitz SP, Rwiyereka AK, Rurangwa T, Shepard DS, Rwamasirabo E, Isaacson KB, van der Poel S, Racowsky C. Infertility services integrated within the maternal health department of a public hospital in a low-income country, Rwanda. F S Rep 2023; 4:130-142. [PMID: 37398610 PMCID: PMC10310971 DOI: 10.1016/j.xfre.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 07/04/2023] Open
Abstract
Objective To describe the initiation, integration, and costs of reduced-cost infertility services within the maternal health department of a public hospital in a low-income country. Design Retrospective review of the clinical and laboratory components of patients undergoing in vitro fertilization (IVF) treatment in Rwanda from 2018 to 2020. Setting Academic tertiary referral hospital in Rwanda. Patients Patients seeking infertility services beyond the primary gynecological options. Interventions The national government furnished facilities and personnel, and the Rwanda Infertility Initiative, an international nongovernmental organization, provided training, equipment, and materials. The incidence of retrieval, fertilization, embryo cleavage, transfer, and conception (observed until ultrasound verification of intrauterine pregnancy with fetal heartbeat) were analyzed. Cost calculations used the government-issued tariff specifying insurers' payments and patients' copayments with projected delivery rates using early literature. Main Outcome Measures Assessment of functional clinical and laboratory infertility services and costs. Results A total of 207 IVF cycles were initiated, 60 of which led to transfer of ≥1 high-grade embryo and 5 to ongoing pregnancies. The projected average cost per cycle was 1,521 USD. Using optimistic and conservative assumptions, the estimated costs per delivery for women <35 years were 4,540 and 5,156 USD, respectively. Conclusions Reduced-cost infertility services were initiated and integrated within a maternal health department of a public hospital in a low-income country. This integration required commitment, collaboration, leadership, and a universal health financing system. Low-income countries, such as Rwanda, might consider infertility treatment and IVF for younger patients as part of an equitable and affordable health care benefit.
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Affiliation(s)
- Selwyn P. Oskowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
| | - Angélique K. Rwiyereka
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Schneider Institutes for Health Policy and Research, Institute for Global Health and Development, Heller School of Social Policy, Brandeis University, Waltham, Massachusetts
| | - Théogène Rurangwa
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Department of Obstetrics and Gynecology, Rwanda Military Hospital, Kigali, Rwanda
| | - Donald S. Shepard
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Schneider Institutes for Health Policy and Research, Institute for Global Health and Development, Heller School of Social Policy, Brandeis University, Waltham, Massachusetts
| | - Emile Rwamasirabo
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Rwanda Accreditation Agency for Quality Healthcare (RAAQH), Kigali, Rwanda
| | - Keith B. Isaacson
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
| | | | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
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10
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Nuwamanya E, Babigumira JB, Svensson M. Cost-effectiveness of increased contraceptive coverage using family planning benefits cards compared with the standard of care for young women in Uganda. Contracept Reprod Med 2023; 8:21. [PMID: 36782307 PMCID: PMC9926799 DOI: 10.1186/s40834-022-00206-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/04/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Uganda has a high population growth rate of 3%, partly due to limited access to and low usage of contraception. This study assessed the cost-effectiveness of the family planning benefits cards (FPBC) program compared to standard of care (SOC). The FPBC program was initiated to increase access to modern contraception among young women in slums in Kampala, Uganda. METHODS We developed a decision-analytic model (decision tree) and parameterized it using primary intervention data together with previously published data. In the base case, a sexually active woman from an urban slum, aged 18 to 30 years, was modelled over a one-year time horizon from both the modified societal and provider perspectives. The main model outcomes included the probability of unintended conception, costs, and incremental cost-effectiveness ratio (ICER) in terms of cost per unwanted pregnancy averted. Both deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of the modelling results. All costs were reported in 2022 US dollars, and analyses were conducted in Microsoft Excel. RESULTS In the base case analysis, the FPBC was superior to the SOC in outcomes. The probability of conception was lower in the FPBC than in the SOC (0.20 vs. 0.44). The average societal and provider costs were higher in the FPBC than in the SOC, i.e., $195 vs. $164 and $193 vs. $163, respectively. The ICER comparing the FPBC to the SOC was $125 per percentage reduction in the probability of unwanted conception from the societal perspective and $121 from the provider perspective. The results were robust to sensitivity analyses. CONCLUSION Given Uganda's GDP per capita of $1046 in 2022, the FPBC is highly cost-effective compared to the SOC in reducing unintended pregnancies among young women in low-income settings. It can even get cheaper in the long run due to the low marginal costs of deploying additional FPBCs. TRIAL REGISTRATION MUREC1/7 No. 10/05-17. Registered on July 19, 2017.
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Affiliation(s)
- Elly Nuwamanya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, 40530, Uganda. .,GHE Consulting, P.O Box 27011, Kampala, Uganda. .,Department of Community Medicine and Public Health, Sahlgrenska Academy, University of Gothenburg, P. O Box 414, 40530, Gothenburg, Sweden.
| | | | - Mikael Svensson
- grid.8761.80000 0000 9919 9582Department of Community Medicine and Public Health, Sahlgrenska Academy, University of Gothenburg, P. O Box 414, 40530 Gothenburg, Sweden
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11
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Mukuru M, Gorry J, Kiwanuka SN, Gibson L, Musoke D, Ssengooba F. Designed to Fail? Revisiting Uganda's Maternal Health Policies to Understand Policy Design Issues Underpinning Missed Targets for Reduction of Maternal Mortality Ratio (MMR): 2000-2015. Int J Health Policy Manag 2022; 11:2124-2134. [PMID: 34664495 PMCID: PMC9808297 DOI: 10.34172/ijhpm.2021.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 09/06/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to '3Cs' (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming. METHODS We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the 'three delay model' combined with a broader literature on 'policy mixing.' RESULTS Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues. CONCLUSION The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the 'three delays' but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.
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Affiliation(s)
- Moses Mukuru
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jonathan Gorry
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Suzanne N. Kiwanuka
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Linda Gibson
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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12
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Musiimenta A, Tumuhimbise W, Atukunda EC, Mugaba AT, Asasira J, Katusiime J, Zender R, Pinkwart N, Mugyenyi GR, Haberer JE. A mobile health app may improve maternal and child health knowledge and practices among rural women with limited education in Uganda: a pilot randomized controlled trial. JAMIA Open 2022; 5:ooac081. [PMID: 36225894 PMCID: PMC9542753 DOI: 10.1093/jamiaopen/ooac081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 08/24/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022] Open
Abstract
Objective This article describes the impact of a mobile health app (MatHealth App) on maternal and child health knowledge and practices among women with limited education. Materials and methods Pregnant women initiating antenatal care (ANC) were randomized (1:1) to the MatHealth App versus routine care. Participants were followed until 6 weeks after delivery. Questionnaires for assessing knowledge and practices were administered to participants from both arms at baseline and endline. Using logistic regression, we estimated the difference in odds of having maternal health knowledge. We reviewed clinic records to capture maternal health practices. Results Of the 80 enrolled participants, 69 (86%) completed the study with a median follow-up of 6 months. Women in the MatHealth arm had 8.2 (P = .19), 3.6 (P = .14), and 6.4 (P = .25), respectively higher odds of knowing (1) the recommended gestation period for starting ANC, (2) the recommended number of ANC visits, and (3) the timing and frequency of recommended human immunodeficiency virus (HIV) testing, respectively, compared to those in the routine care arm. All women in the MatHealth App arm exclusively breastfed their babies, and brought them at 6 weeks for HIV testing, compared to the routine care arm. Just over half of the women attended at least 4 prenatal visits across the 2 arms. The main reason for noncompliance to ANC appointments was a lack of transport to the clinic. Discussion and conclusion The app increased knowledge and practices although not reaching statistical significance. Future efforts can focus on addressing social and economic issues and assessing clinical outcomes.
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Affiliation(s)
- Angella Musiimenta
- Corresponding Author: Angella Musiimenta, PhD, Department of Information Technology, Mbarara University of Science and Technology, P.O. Box 653, Mbarara, Uganda;
| | - Wilson Tumuhimbise
- Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Esther C Atukunda
- Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Aaron T Mugaba
- Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda,Angels Compassion Research and Development Initiative, Mbarara, Uganda
| | - Justus Asasira
- Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jane Katusiime
- Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Raphael Zender
- Department of Computer Science, Humboldt Universitat zu Berlin, Berlin, Germany
| | - Niels Pinkwart
- Department of Computer Science, Humboldt Universitat zu Berlin, Berlin, Germany
| | | | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA,Medicine Department, Harvard Medical School, Boston, Massachusetts, USA
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13
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Palmer T, Batura N, Skordis J, Stirrup O, Vanhuyse F, Copas A, Odhiambo A, Ogendo N, Dickin S, Mwaki A, Haghparast-Bidgoli H. Economic evaluation of a conditional cash transfer to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000128. [PMID: 36962294 PMCID: PMC10021150 DOI: 10.1371/journal.pgph.0000128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022]
Abstract
There is limited evidence on the cost and cost-effectiveness of cash transfer programmes to improve maternal and child health in Kenya and other sub-Saharan African countries. This article presents the economic evaluation results of the Afya trial, assessing the costs, cost-effectiveness and equity impact of a demand-side financing intervention that promotes utilisation of maternal health services in rural Kenya. The cost of implementing the Afya intervention was estimated from a provider perspective. Cost data were collected prospectively from all implementing and non-implementing partners, and from health service providers. Cost-efficiency was analysed using cost-transfer ratios and cost per mother enrolled into the intervention. Cost-effectiveness was assessed as cost per additional eligible antenatal care visit as a result of the intervention, when compared with standard care. The equity impact of the intervention was also assessed using a multidimensional poverty index (MPI). Programme cost per mother enrolled was International (INT)$313 of which INT$ 92 consisted of direct transfer payments, suggesting a cost transfer ratio of 2.4. Direct healthcare utilisation costs reflected a small proportion of total provider costs, amounting to INT$ 21,756. The total provider cost of the Afya intervention was INT$808,942. The provider cost per additional eligible ANC visit was INT$1,035. This is substantially higher than estimated annual health expenditure per capita at the county level of $INT61. MPI estimates suggest around 27.4% of participant households were multidimensionally poor. MPI quintiles did not significantly modify the intervention effect, suggesting the impact of the intervention did not differ by socioeconomic status. Based on the available evidence, it is not possible to conclude whether the Afya intervention was cost-effective. A simple comparison with current health expenditure in Siaya county suggests that the intervention as implemented is likely to be unaffordable. Consideration needs to be given to strengthening the supply-side of the cash transfer intervention before replication or uptake at scale.
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Affiliation(s)
- Tom Palmer
- Institute for Global Health, University College London, London, United Kingdom
| | - Neha Batura
- Institute for Global Health, University College London, London, United Kingdom
| | - Jolene Skordis
- Institute for Global Health, University College London, London, United Kingdom
| | - Oliver Stirrup
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Andrew Copas
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Sarah Dickin
- Stockholm Environment Institute, Stockholm, Sweden
| | - Alex Mwaki
- Safe Water and AIDS Project (SWAP), Kisumu, Kenya
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14
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Lee S, Adam AJ. Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:295. [PMID: 35010561 PMCID: PMC8744962 DOI: 10.3390/ijerph19010295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/25/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.
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Affiliation(s)
- Seohyun Lee
- Department of Global Public Administration, Mirae Campus, Yonsei University, Wonju 26493, Korea
| | - Abdul-jabiru Adam
- Department of Public Administration, Mirae Campus, Yonsei University Graduate School, Wonju 26493, Korea;
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15
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Das R, Farzana FD, Sultana Z, Mukherji K, Baayo A, Sultana M, Ali N, Chisti MJ, Sarker SA, Ahmed T, Faruque A. Evaluation of SIMESON, a training program to improve access to quality health care for pregnant women and newborn in different healthcare facilities of northern Bangladesh. Nurs Open 2021; 9:801-815. [PMID: 34784452 PMCID: PMC8685868 DOI: 10.1002/nop2.1131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 01/02/2023] Open
Abstract
Aim The study aims to explore the current knowledge and skills of healthcare providers already trained by SIMESON (simulation for essential skills for obstetrical and neonatal care), in reviewing perinatal health situations including current status of healthcare facilities and cost estimation. Design It was an observational study. Methods Cost estimation following both quantitative and qualitative approaches was also attempted. Result Knowledge and skills of 88 healthcare providers about the provision of normal delivery and immediate postpartum care, management of postpartum haemorrhage (PPH), retained placenta and use of bag and mask ventilation to help a baby breathe were found to be considerably strengthened following SIMESON training. During the 6 months after training, there were 477 PPH cases managed successfully with only one death; neonatal deaths observed were 6.6/1,000 live births; twice the number of facility deliveries; and 80% use rate of Ambu bag for helping baby breathe. The estimated cost per trainee was 395.68 USD, and 5.85 USD per beneficiary.
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Affiliation(s)
- Rina Das
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Fahmida Dil Farzana
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Zakia Sultana
- Terre des hommes foundation (Tdh), Dhaka, Bangladesh
| | | | - Adnan Baayo
- Terre des hommes foundation (Tdh), Dhaka, Bangladesh
| | - Marufa Sultana
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Nausad Ali
- Bangladesh Institute of Development Studies, Dhaka, Bangladesh
| | | | - Shafiqul Alam Sarker
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Asg Faruque
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
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16
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Cleary S. Economic evaluation and health systems strengthening: a review of the literature. Health Policy Plan 2021; 35:1413-1423. [PMID: 33230546 DOI: 10.1093/heapol/czaa116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 01/03/2023] Open
Abstract
Health systems strengthening (HSS) is firmly on the global health and development agenda. While a growing evidence base seeks to understand the effectiveness of HSS, there is limited evidence regarding cost and cost-effectiveness. Without such evidence, it is hard to argue that HSS represents value for money and the level of investment needed cannot be quantified. This paper seeks to review the literature regarding the economic evaluation of HSS from low- and middle-income country (LMIC) settings, and to contribute towards the development of methods for the economic evaluation of HSS. A systematic search for literature was conducted in PubMed, Scopus and the Health Systems Evidence database. MeSH terms related to economic evaluation were combined with key words related to the concept of HSS. Of the 204 records retrieved, 52 were retained for full text review and 33 were included. Of these, 67% were published between January 2015 and June 2019. While many HSS interventions have system wide impacts, most studies (71%) investigated these impacts using a disease-specific lens (e.g. the impact of quality of care improvements on uptake of facility deliveries). HSS investments were categorized, with the majority being investments in platform efficiency (e.g. quality of care), followed by simultaneous investment in platform efficiency and platform capacity (e.g. quality of care and task shifting). This review identified a growing body of work seeking to undertake and/or conceptualize the economic evaluation of HSS in low- and middle-income countries. The majority assess HSS interventions using a disease-specific or programmatic lens, treating HSS in a similar manner to the economic evaluation of medicines and diagnostics. While this approach misses potential economies of scope from HSS investments, it allows for a preliminary understanding of relative value for money. Future research is needed to complement the emerging evidence base.
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Affiliation(s)
- Susan Cleary
- Health Economics Unit/Division, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
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17
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Joiner A, Lee A, Chowa P, Kharel R, Kumar L, Caruzzo NM, Ramirez T, Reynolds L, Sakita F, Van Vleet L, von Isenburg M, Yaffee AQ, Staton C, Vissoci JRN. Access to care solutions in healthcare for obstetric care in Africa: A systematic review. PLoS One 2021; 16:e0252583. [PMID: 34086753 PMCID: PMC8177460 DOI: 10.1371/journal.pone.0252583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/18/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context. METHODS The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach. FINDINGS A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention. INTERPRETATION Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.
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Affiliation(s)
- Anjni Joiner
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Austin Lee
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Phindile Chowa
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ramu Kharel
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Lekshmi Kumar
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Nayara Malheiros Caruzzo
- Physical Education Department, State University of Maringá, Maringá, PR, United States of America
| | - Thais Ramirez
- Duke Global Health Institute, Durham, NC, United States of America
| | - Lindy Reynolds
- University of Alabama School of Public Health, Birmingham, AL, United States of America
| | - Francis Sakita
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Lee Van Vleet
- Durham County Emergency Services, Durham, NC, United States of America
| | - Megan von Isenburg
- Medical Center Library, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Anna Quay Yaffee
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Catherine Staton
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
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18
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Lilford R, Nepogodiev D, Chilton PJ, Watson SI, Erlangga D, Diggle P, Girling AJ, Sculpher M. Methodological issues in economic evaluations of emergency transport systems in low-income and middle-income countries. BMJ Glob Health 2021; 6:bmjgh-2020-004723. [PMID: 33737285 PMCID: PMC7977070 DOI: 10.1136/bmjgh-2020-004723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 11/30/2022] Open
Abstract
A recent systematic review identified few papers on the economic evaluation of systems for emergency transport of acutely ill or injured patients. In addition, we found no articles dealing with the methodological challenges posed by such studies in low-income or middle-income countries. We therefore carried out an analysis of issues that are of particular salience to this important topic. This is an intellectual study in which we develop models, identify their limitations, suggest potential extensions to the models and discuss priorities for empirical studies to populate models. First, we develop a general model to calculate changes in survival contingent on the reduced time to treatment that an emergency transport system is designed to achieve. Second, we develop a model to estimate transfer times over an area that will be served by a proposed transfer system. Third, we discuss difficulties in obtaining parameters with which to populate the models. Fourth, we discuss costs, both direct and indirect, of an emergency transfer service. Fifth, we discuss the issue that outcomes other than survival should be considered and that the effects of a service are a weighted sum over all the conditions and severities for which the service caters. Lastly, based on the above work, we identify priorities for research. To our knowledge, this is the first study to identify and frame issues in the health economics of acute transfer systems and to develop models to calculate survival rates from basic parameters, such as time delay/survival relationships, that vary by intervention type and context.
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Affiliation(s)
- Richard Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Dmitri Nepogodiev
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Peter J Chilton
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Samuel I Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Darius Erlangga
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Diggle
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Alan J Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
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19
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Musiimenta A, Tumuhimbise W, Pinkwart N, Katusiime J, Mugyenyi G, Atukunda EC. A mobile phone-based multimedia intervention to support maternal health is acceptable and feasible among illiterate pregnant women in Uganda: Qualitative findings from a pilot randomized controlled trial. Digit Health 2021; 7:2055207620986296. [PMID: 33717497 PMCID: PMC7917428 DOI: 10.1177/2055207620986296] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 12/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Uganda's maternal mortality rate remains unacceptably high. Mobile phones can potentially provide affordable means of accessing maternal health services even among the otherwise hard-to-reach populations. Evidence about the acceptability and feasibility of mobile phone-based interventions targeting illiterate women, however, is limited. OBJECTIVE To assess the acceptability and feasibility of a mobile phone-based multimedia application (MatHealth app) to support maternal health amongst illiterate pregnant women in rural southwestern Uganda. METHODS 80 pregnant women initiating antenatal care from Mbarara regional referral hospital were enrolled in a pilot randomized controlled trial and followed until six weeks after delivery. The 40 women in the intervention group received a MatHealth app composed of educational videos/audios, clinic appointment reminders, and the calling function. Qualitative interviews on acceptability of this technology were carried out with 30 of the intervention participants. An inductive, content analytic approach was used to analyze qualitative data. Quantitative feasibility data were recorded and summarized descriptively. RESULTS Participants reported that the intervention is acceptable as it enabled them adopt good maternal health practices, enhanced social support from spouses, provided clinic appointment reminders, and facilitated communication with healthcare providers. Challenges included: phone sharing (74%), accidental deletion of the application 15 (43%), lack of electricity 15 (43%), and inability to set up a reminder function 20 (57%). CONCLUSION The MatHealth app is an acceptable and feasible intervention among illiterate women, in a resource limited setting. Future efforts should focus on optimized application design, spouse orientation, and incorporating economic support to overcome the challenges we encountered.
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Affiliation(s)
- Angella Musiimenta
- Department of Information Technology, Mbarara, Mbarara University of Science and Technology, Uganda
- Angels Compassion Organisation, Mbarara, Uganda
| | - Wilson Tumuhimbise
- Department of Information Technology, Mbarara, Mbarara University of Science and Technology, Uganda
| | - Niels Pinkwart
- Computer Science Department, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jane Katusiime
- Department of Information Technology, Mbarara, Mbarara University of Science and Technology, Uganda
| | - Godfrey Mugyenyi
- Department of Information Technology, Mbarara, Mbarara University of Science and Technology, Uganda
| | - Esther C Atukunda
- Department of Information Technology, Mbarara, Mbarara University of Science and Technology, Uganda
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20
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Chinkhumba J, De Allegri M, Brenner S, Muula A, Robberstad B. The cost-effectiveness of using results-based financing to reduce maternal and perinatal mortality in Malawi. BMJ Glob Health 2020; 5:e002260. [PMID: 32444363 PMCID: PMC7247376 DOI: 10.1136/bmjgh-2019-002260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/13/2020] [Accepted: 04/15/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Results-based financing (RBF) is being promoted to increase coverage and quality of maternal and perinatal healthcare in sub-Saharan Africa (SSA) countries. Evidence on the cost-effectiveness of RBF is limited. We assessed the cost-effectiveness within the context of an RBF intervention, including performance-based financing and conditional cash transfers, in rural Malawi. METHODS We used a decision tree model to estimate expected costs and effects of RBF compared with status quo care during single pregnancy episodes. RBF effects on maternal case fatality rates were modelled based on data from a maternal and perinatal programme evaluation in Zambia and Uganda. We obtained complementary epidemiological information from the published literature. Service utilisation rates for normal and complicated deliveries and associated costs of care were based on the RBF intervention in Malawi. Costs were estimated from a societal perspective. We estimated incremental cost-effectiveness ratios per disability adjusted life year (DALY) averted, death averted and life-year gained (LYG) and conducted sensitivity analyses to how robust results were to variations in key model parameters. RESULTS Relative to status quo, RBF implied incremental costs of US$1122, US$26 220 and US$987 per additional DALY averted, death averted and LYG, respectively. The share of non-RBF facilities that provide quality care, life expectancy of mothers at time of delivery and the share of births in non-RBF facilities strongly influenced cost-effectiveness values. At a willingness to pay of US$1485 (3 times Malawi gross domestic product per capita) per DALY averted, RBF has a 77% probability of being cost-effective. CONCLUSIONS At high thresholds of wiliness-to-pay, RBF is a cost-effective intervention to improve quality of maternal and perinatal healthcare and outcomes, compared with the non-RBF based approach. More RBF cost-effectiveness analyses are needed in the SSA region to complement the few published studies and narrow the uncertainties surrounding cost-effectiveness estimates.
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Affiliation(s)
- Jobiba Chinkhumba
- Department of Health Systems and Policy, Health Economics and Policy Unit, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Global Public Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Manuela De Allegri
- Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Stephan Brenner
- Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Adamson Muula
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Bjarne Robberstad
- Department of Global Public Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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Nkangu MN, Okwen PM, Mbuagbaw L, Weledji DK, Roberts JH, Yaya S. A protocol for a pilot cluster randomized control trial of e-vouchers and mobile phone application to enhance access to maternal health services in Cameroon. Pilot Feasibility Stud 2020; 6:45. [PMID: 32313683 PMCID: PMC7155248 DOI: 10.1186/s40814-020-00589-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/20/2020] [Indexed: 01/26/2023] Open
Abstract
Background Cameroon still has relatively high maternal mortality rate (MMR) of 596/100,000 live births. Approximately 40% of births are unattended by skilled healthcare personnel with high out-of-pocket expenditures. Poor resource allocation, poorly functioning referral systems, long trekking distances to health facilities, all of which lead to low rates of use of maternal health services. Objectives The aim of this pilot study is to explore perception and acceptability of mobile health (mhealth) and e-voucher and to determine the feasibility of conducting a large cluster randomized trial to determine the effects of combining e-vouchers and a mobile application compared with usual care in improving access to and use of maternal health services. Methods This is a multimethod study that comprises two phases. The first phase is the development of the mobile phone app, which includes a qualitative formative study through in-depth key informant interviews and focus group discussions. The second phase is a cluster randomized control trial assessing the combination of e-vouchers and a mobile application compared with usual care in improving access to and use of maternal health services. Feasibility will be determined based on evaluating randomization, contamination, enrollment rate, complete follow up, compliance rate, success in matching data from different sources, and data completeness. Ethics and discussion Ethics approval has been granted, and the trial has been registered in the Pan-African Clinical Trials Registry. We will disseminate our findings through peer-reviewed manuscripts and conference presentations. Findings from this study will inform the design and conduct of a larger randomized trial. Trial registration PACTR201808703097367. The trial on the Pan African Clinical Trials Registry.
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Affiliation(s)
- Miriam N Nkangu
- 1School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Health Promotion Alliance Cameroon (HPAC), Yaounde, Cameroon.,9WHO Collaborating Center for Knowledge Translation and Health Technology Assessment in Health Equity, Ottawa University, Ottawa, Canada.,10Bruyere Research Institute, Ottawa, Canada
| | | | - Lawrence Mbuagbaw
- 3Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,4Biostatistics Unit, The Research Institute, St Joseph's Healthcare Hamilton, Hamilton, Canada.,Centre for the Development of Best Practices in Health, Yaounde, Cameroon
| | | | - Janet Hatcher Roberts
- 1School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,9WHO Collaborating Center for Knowledge Translation and Health Technology Assessment in Health Equity, Ottawa University, Ottawa, Canada.,10Bruyere Research Institute, Ottawa, Canada
| | - Sanni Yaya
- 8School of International Development and Global Studies, University of Ottawa, Ottawa, Canada
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22
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Muller N, McMahon SA, De Neve JW, Funke A, Bärnighausen T, Rajemison EN, Lacroze E, Emmrich JV, Knauss S. Facilitators and barriers to the implementation of a Mobile Health Wallet for pregnancy-related health care: A qualitative study of stakeholders' perceptions in Madagascar. PLoS One 2020; 15:e0228017. [PMID: 32004331 PMCID: PMC6993972 DOI: 10.1371/journal.pone.0228017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/05/2020] [Indexed: 11/18/2022] Open
Abstract
Financial barriers are a major obstacle to accessing maternal health care services in low-resource settings. In Madagascar, less than half of live births are attended by skilled health staff. Although mobile money-based savings and payment systems are often used to pay for a variety of services, including health care, data on the implications of a dedicated mobile money wallet restricted to health-related spending during pregnancy-a mobile health wallet (MHW)-are not well understood. In cooperation with the Madagascan Ministry of Health, this study aims to elicit the perceptions, experiences, and recommendations of key stakeholders in relation to a MHW amid a pilot study in 31 state-funded health care facilities. We conducted a two-stage qualitative study using semi-structured in-depth interviews with stakeholders (N = 21) representing the following groups: community representatives, health care providers, health officials and representatives from phone provider companies. Interviews were conducted in Atsimondrano and Renivohitra districts, between November and December of 2017. Data was coded thematically using inductive and deductive approaches, and found to align with a social ecological model. Key facilitators for successful implementation of the MHW, include (i) close collaboration with existing communal structures and (ii) creation of an incentive scheme to reward pregnant women to save. Key barriers to the application of the MHW in the study zone include (i) disruption of informal benefits for health care providers related to the current cash-based payment system, (ii) low mobile phone ownership, (iii) illiteracy among the target population, and (iv) failure of the MHW to overcome essential access barriers towards institutional health care services such as fear of unpredictable expenses. The MHW was perceived as a potential solution to reduce disparities in access to maternal health care. To ensure success of the MHW, direct demand-side and provider-side financial incentives merit consideration.
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Affiliation(s)
- Nadine Muller
- Medical Faculty, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Infectious Diseases and Pulmonary Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Corporate Member of Freie Universität Berlin, Berlin, Germany
- Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- * E-mail:
| | - Shannon A. McMahon
- Medical Faculty, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jan-Walter De Neve
- Medical Faculty, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Alexej Funke
- Medical Faculty, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Till Bärnighausen
- Medical Faculty, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute, Somkhele and Durban, South Africa
| | - Elsa N. Rajemison
- Medical Faculty, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Etienne Lacroze
- Medical Faculty, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Julius V. Emmrich
- Corporate Member of Freie Universität Berlin, Berlin, Germany
- Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology and Center for Stroke Research, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Samuel Knauss
- Corporate Member of Freie Universität Berlin, Berlin, Germany
- Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology and Center for Stroke Research, Charité—Universitätsmedizin Berlin, Berlin, Germany
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23
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Batura N, Skordis J, Palmer T, Odiambo A, Copas A, Vanhuyse F, Dickin S, Eleveld A, Mwaki A, Ochieng C, Haghparast-Bidgoli H. Cost-effectiveness of conditional cash transfers to retain women in the continuum of care during pregnancy, birth and the postnatal period: protocol for an economic evaluation of the Afya trial in Kenya. BMJ Open 2019; 9:e032161. [PMID: 31699743 PMCID: PMC6858100 DOI: 10.1136/bmjopen-2019-032161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION A wealth of evidence from a range of country settings indicates that antenatal care, facility delivery and postnatal care can reduce maternal and child mortality and morbidity in high-burden settings. However, the utilisation of these services by pregnant women, particularly in low/middle-income country settings, is well below that recommended by the WHO. The Afya trial aims to assess the impact, cost-effectiveness and scalability of conditional cash transfers to promote increased utilisation of these services in rural Kenya and thus retain women in the continuum of care during pregnancy, birth and the postnatal period. This protocol describes the planned economic evaluation of the Afya trial. METHODS AND ANALYSIS The economic evaluation will be conducted from the provider perspective as a within-trial analysis to evaluate the incremental costs and health outcomes of the cash transfer programme compared with the status quo. Incremental cost-effectiveness ratios will be presented along with a cost-consequence analysis where the incremental costs and all statistically significant outcomes will be listed separately. Sensitivity analyses will be undertaken to explore uncertainty and to ensure that results are robust. A fiscal space assessment will explore the affordability of the intervention. In addition, an analysis of equity impact of the intervention will be conducted. ETHICS AND DISSEMINATION The study has received ethics approval from the Maseno University Ethics Review Committee, REF MSU/DRPI/MUERC/00294/16. The results of the economic evaluation will be disseminated in a peer-reviewed journal and presented at a relevant international conference. TRIAL REGISTRATION NUMBER NCT03021070.
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Affiliation(s)
- Neha Batura
- Institute for Global Health, University College London, London, UK
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Tom Palmer
- Institute for Global Health, University College London, London, UK
| | | | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | | | - Sarah Dickin
- Stockholm Environment Institute, Stockholm, Sweden
| | | | - Alex Mwaki
- Safe Water and AIDS Project, Kisumu, Kenya
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24
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Serván‐Mori E, Mendoza MÁ, Chivardi C, Pineda‐Antúnez C, Rodríguez‐Franco R, Nigenda G. A spatio‐temporal cluster analysis of technical efficiency in the production of outpatient maternal health services and its structural correlates in México. Int J Health Plann Manage 2019; 34:e1417-e1436. [DOI: 10.1002/hpm.2785] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | - Carlos Chivardi
- Center for Health Systems Research National Institute of Public Health Cuernavaca Morelos México
| | - Carlos Pineda‐Antúnez
- Center for Health Systems Research National Institute of Public Health Cuernavaca Morelos México
| | - Roxana Rodríguez‐Franco
- Center for Health Systems Research National Institute of Public Health Cuernavaca Morelos México
| | - Gustavo Nigenda
- National School of Nursing and Obstetrics National Autonomous University of Mexico Mexico City México
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Yorlets RR, Iverson KR, Leslie HH, Gage AD, Roder-DeWan S, Nsona H, Shrime MG. Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi. BMJ Glob Health 2019; 4:e000930. [PMID: 30997159 PMCID: PMC6441245 DOI: 10.1136/bmjgh-2018-000930] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 11/14/2018] [Accepted: 12/13/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women's choice of delivery facility. METHODS A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion. RESULTS Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women. CONCLUSION For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.
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Affiliation(s)
- Rachel R Yorlets
- Department of Plastic & Oral Surgery, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine R Iverson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Anna Davies Gage
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Sanam Roder-DeWan
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Humphreys Nsona
- Integrated Management of Childhood Illnesses (IMCI), Ministry of Health, Lilongwe, Malawi
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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26
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Johns B, Hangoma P, Atuyambe L, Faye S, Tumwine M, Zulu C, Levitt M, Tembo T, Healey J, Li R, Mugasha C, Serbanescu F, Conlon CM. The Costs and Cost-Effectiveness of a District-Strengthening Strategy to Mitigate the 3 Delays to Quality Maternal Health Care: Results From Uganda and Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S104-S122. [PMID: 30867212 PMCID: PMC6519668 DOI: 10.9745/ghsp-d-18-00429] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/27/2019] [Indexed: 11/15/2022]
Abstract
A comprehensive district-strengthening approach to address maternal and newborn health was estimated to cost US$177 per life-year gained in Uganda and $206 per life-year gained in Zambia. The approach represents a very cost-effective health investment compared to GDP per capita. The primary objective of this study was to estimate the costs and the incremental cost-effectiveness of maternal and newborn care associated with the Saving Mothers, Giving Life (SMGL) initiative—a comprehensive district-strengthening approach addressing the 3 delays associated with maternal mortality—in Uganda and Zambia. To assess effectiveness, we used a before-after design comparing facility outcome data from 2012 (before) and 2016 (after). To estimate costs, we used unit costs collected from comparison districts in 2016 coupled with data on health services utilization from 2012 in SMGL-supported districts to estimate the costs before the start of SMGL. We collected data from health facilities, ministerial health offices, and implementing partners for the year 2016 in 2 SMGL-supported districts in each country and in 3 comparison non-SMGL districts (2 in Zambia, 1 in Uganda). Incremental costs for maternal and newborn health care per SMGL-supported district in 2016 was estimated to be US$845,000 in Uganda and $760,000 in Zambia. The incremental cost per delivery was estimated to be $38 in Uganda and $95 in Zambia. For the districts included in this study, SMGL maternal and newborn health activities were associated with approximately 164 deaths averted in Uganda and 121 deaths averted in Zambia in 2016 compared to 2012. In Uganda, the cost per death averted was $10,311, or $177 per life-year gained. In Zambia, the cost per death averted was $12,514, or $206 per life-year gained. The SMGL approach can be very cost-effective, with the cost per life-year gained as a percentage of the gross domestic product (GDP) being 25.6% and 16.4% in Uganda and Zambia, respectively. In terms of affordability, the SMGL approach could be paid for by increasing health spending from 7.3% to 7.5% of GDP in Uganda and from 5.4% to 5.8% in Zambia.
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Affiliation(s)
- Benjamin Johns
- International Development Division, Abt Associates Inc., Bethesda, MD, USA.
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Lynn Atuyambe
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sophie Faye
- International Development Division, Abt Associates Inc., Bethesda, MD, USA
| | - Mark Tumwine
- Uganda Country Office, U.S. Centers for Disease Control and Prevention, Entebbe, Uganda
| | - Collen Zulu
- U.S. Agency for International Development, Lusaka, Zambia
| | - Marta Levitt
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA, and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria
| | - Tannia Tembo
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia
| | - Rui Li
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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27
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Deidda M, Geue C, Kreif N, Dundas R, McIntosh E. A framework for conducting economic evaluations alongside natural experiments. Soc Sci Med 2019; 220:353-361. [PMID: 30513485 PMCID: PMC6323352 DOI: 10.1016/j.socscimed.2018.11.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/20/2018] [Accepted: 11/22/2018] [Indexed: 11/30/2022]
Abstract
Internationally, policy makers are increasingly focussed on reducing the detrimental consequences and rising costs associated with unhealthy diets, inactivity, smoking, alcohol and other risk factors on the health of their populations. This has led to an increase in the demand for evidence-based, cost-effective Population Health Interventions (PHIs) to reverse this trend. Given that research designs such as randomised controlled trials (RCTs) are often not suited to the evaluation of PHIs, Natural Experiments (NEs) are now frequently being used as a design to evaluate such complex, preventive PHIs. However, current guidance for economic evaluation focusses on RCT designs and therefore does not address the specific challenges of NE designs. Using such guidance can lead to sub-optimal design, data collection and analysis for NEs, leading to bias in the estimated effectiveness and cost-effectiveness of the PHI. As a consequence, there is a growing recognition of the need to identify a robust methodological framework for the design and conducting of economic evaluations alongside such NEs. This paper outlines the challenges inherent to the design and conduct of economic evaluations of PHIs alongside NEs, providing a comprehensive framework and outlining a research agenda in this area.
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Affiliation(s)
- Manuela Deidda
- Health Economics & Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom.
| | - Claudia Geue
- Health Economics & Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom
| | - Noemi Kreif
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, United Kingdom
| | - Ruth Dundas
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3QB, United Kingdom
| | - Emma McIntosh
- Health Economics & Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom
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Bowser DM, Shepard DS, Nandakumar A, Okunogbe A, Morrill T, Halasa-Rappell Y, Jordan M, Mushi F, Boyce C, Erhunmwunse OA. Cost Effectiveness of Mobile Health for Antenatal Care and Facility Births in Nigeria. Ann Glob Health 2018. [PMID: 30779506 PMCID: PMC6748180 DOI: 10.29024/aogh.2364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery. Methods: The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis. Findings: The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved. Conclusion: These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.
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Affiliation(s)
- Diana M Bowser
- Heller School for Social Policy and Management, Brandeis University, US
| | - Donald S Shepard
- Heller School for Social Policy and Management, Brandeis University, US
| | | | | | | | | | - Monica Jordan
- Heller School for Social Policy and Management, Brandeis University, US
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29
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Bowser DM, Shepard DS, Nandakumar A, Okunogbe A, Morrill T, Halasa-Rappell Y, Jordan M, Mushi F, Boyce C, Erhunmwunse OA. Cost Effectiveness of Mobile Health for Antenatal Care and Facility Births in Nigeria. Ann Glob Health 2018; 84:592-602. [PMID: 30779506 DOI: 10.9204/aogh.2364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery. METHODS The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis. FINDINGS The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved. CONCLUSION These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.
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Affiliation(s)
- Diana M Bowser
- Heller School for Social Policy and Management, Brandeis University, US
| | - Donald S Shepard
- Heller School for Social Policy and Management, Brandeis University, US
| | | | | | | | | | - Monica Jordan
- Heller School for Social Policy and Management, Brandeis University, US
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30
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Benova L, Dennis ML, Lange IL, Campbell OMR, Waiswa P, Haemmerli M, Fernandez Y, Kerber K, Lawn JE, Santos AC, Matovu F, Macleod D, Goodman C, Penn-Kekana L, Ssengooba F, Lynch CA. Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys. BMC Health Serv Res 2018; 18:758. [PMID: 30286749 PMCID: PMC6172797 DOI: 10.1186/s12913-018-3546-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 09/17/2018] [Indexed: 11/11/2022] Open
Abstract
Background Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011. Methods We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests. Results Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency; < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components. Conclusions The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care (facility delivery). Providers in both sectors require quality improvements. Achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women despite competing priorities for financial and human resources. Electronic supplementary material The online version of this article (10.1186/s12913-018-3546-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lenka Benova
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Mardieh L Dennis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Isabelle L Lange
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Peter Waiswa
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Yolanda Fernandez
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kate Kerber
- Saving Newborn Lives, Save the Children, 899 North Capitol Street, Suite 900, Washington, DC, 20002, USA.,Indigenous & Global Health Research Group, Department of Medicine, University of Alberta, University Terrace, 8303-112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Joy E Lawn
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Andreia Costa Santos
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Fred Matovu
- School of Economics, Makerere University Kampala, Uganda and Policy Analysis & Development Research Institute (PADRI), Kampala, Uganda
| | - David Macleod
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Freddie Ssengooba
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Caroline A Lynch
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Morgan R, Tetui M, Muhumuza Kananura R, Ekirapa-Kiracho E, George AS. Gender dynamics affecting maternal health and health care access and use in Uganda. Health Policy Plan 2018; 32:v13-v21. [PMID: 29244103 PMCID: PMC5886085 DOI: 10.1093/heapol/czx011] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 11/13/2022] Open
Abstract
Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women’s access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women’s lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women’s lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women’s workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women’s attitudes and behaviour during pregnancy, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.
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Affiliation(s)
- Rosemary Morgan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Moses Tetui
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.,Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Rornald Muhumuza Kananura
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Elizabeth Ekirapa-Kiracho
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - A S George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,School of Public Health, University of the Western Cape, South Africa
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Prinja S, Bahuguna P, Gupta A, Nimesh R, Gupta M, Thakur JS. Cost effectiveness of mHealth intervention by community health workers for reducing maternal and newborn mortality in rural Uttar Pradesh, India. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:25. [PMID: 29983645 PMCID: PMC6020234 DOI: 10.1186/s12962-018-0110-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 06/13/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A variety of mobile-based health technologies (mHealth) have been developed for use by community health workers to augment their performance. One such mHealth intervention-ReMiND program, was implemented in a poor performing district of India. Despite some research on the extent of its effectiveness, there is significant dearth of evidence on cost-effectiveness of such mHealth interventions. In this paper we evaluated the incremental cost per disability adjusted life year (DALY) averted as a result of ReMiND intervention as compared to routine maternal and child health programs without ReMiND. METHODS A decision tree was parameterized on MS-Excel spreadsheet to estimate the change in DALYs and cost as a result of implementing ReMiND intervention compared with routine care, from both health system and societal perspective. A time horizon of 10 years starting from base year of 2011 was considered appropriate to cover all costs and effects comprehensively. All costs, including those during start-up and implementation phase, besides other costs on the health system or households were estimated. Consequences were measured as part of an impact assessment study which used a quasi-experimental design. Proximal outputs in terms of changes in service coverage were modelled to estimate maternal and infant illnesses and deaths averted, and DALYs averted in Uttar Pradesh state of India. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties. RESULTS Cumulatively, from year 2011 to 2020, implementation of ReMiND intervention in UP would result in a reduction of 312 maternal and 149,468 neonatal deaths. This implies that ReMiND program led to a reduction of 0.2% maternal and 5.3% neonatal deaths. Overall, ReMiND is a cost saving intervention from societal perspective. From health system perspective, ReMiND incurs an incremental cost of INR 12,993 (USD 205) per DALY averted and INR 371,577 (USD 5865) per death averted. CONCLUSIONS Overall, findings of our study suggest strongly that the mHealth intervention as part of ReMiND program is cost saving from a societal perspective and should be considered for replication elsewhere in other states.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Pankaj Bahuguna
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Aditi Gupta
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Ruby Nimesh
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Madhu Gupta
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Jarnail Singh Thakur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
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Cost-effectiveness of health care service delivery interventions in low and middle income countries: a systematic review. Glob Health Res Policy 2018; 3:17. [PMID: 29930989 PMCID: PMC5992822 DOI: 10.1186/s41256-018-0073-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 05/07/2018] [Indexed: 01/17/2023] Open
Abstract
Background Low and middle income countries (LMICs) face severe resource limitations but the highest burden of disease. There is a growing evidence base on effective and cost-effective interventions for these diseases. However, questions remain about the most cost-effective method of delivery for these interventions. We aimed to review the scope, quality, and findings of economic evaluations of service delivery interventions in LMICs. Methods We searched PUBMED, MEDLINE, EconLit, and NHS EED for studies published between 1st January 2000 and 30th October 2016 with no language restrictions. We included all economic evaluations that reported incremental costs and benefits or summary measures of the two such as an incremental cost effectiveness ratio. Studies were grouped by both disease area and outcome measure and permutation plots were completed for similar interventions. Quality was judged by the Drummond checklist. Results Overall, 3818 potentially relevant abstracts were identified of which 101 studies were selected for full text review. Thirty-seven studies were included in the final review. Twenty-three studies reported on interventions we classed as “changing by whom and where care was provided”, specifically interventions that entailed task-shifting from doctors to nurses or community health workers or from facilities into the community. Evidence suggests this type of intervention is likely to be cost-effective or cost-saving. Nine studies reported on quality improvement initiatives, which were generally found to be cost-effective. Quality and methods differed widely limiting comparability of the studies and findings. Conclusions There is significant heterogeneity in the literature, both methodologically and in quality. This renders further comparisons difficult and limits the utility of the available evidence to decision makers.
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Manzi F, Daviaud E, Schellenberg J, Lawn JE, John T, Msemo G, Owen H, Barger D, Hanson C, Borghi J. Improving Newborn Survival in Southern Tanzania (INSIST) trial; community-based maternal and newborn care economic analysis. Health Policy Plan 2018; 32:i33-i41. [PMID: 27335165 PMCID: PMC5886149 DOI: 10.1093/heapol/czw048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2016] [Indexed: 12/19/2022] Open
Abstract
Despite health systems improvements in Tanzania, gaps in the continuum of care for maternal, newborn and child health persist. Recent improvements have largely benefited those over one month of age, leading to a greater proportion of under-five mortality in newborns. Community health workers providing home-based counselling have been championed as uniquely qualified to reach the poorest. We provide financial and economic costs of a volunteer home-based counselling programme in southern Tanzania. Financial costs of the programme were extracted from project accounts. Ministry of Health and Social Welfare costs associated with programme implementation were collected based on staff and project monthly activity plans. Household costs associated with facility-based delivery were also estimated based on exit interviews with post-natal women. Time spent on the programme by implementers was assessed by interviews conducted with volunteers and health staff. The programme involved substantial design and set-up costs. The main drivers of set-up costs were activities related to volunteer training. Total annualized costs (design, set-up and implementation) amounted to nearly US$300 000 for financial costs and just over US$400 000 for economic costs. Volunteers (n = 842) spent just under 14 hours per month on programme-related activities. When volunteer time was valued under economic costs, this input amounted to just under half of the costs of implementation. The economic consequences of increased service use to households were estimated at US$36 985. The intervention cost per mother–newborn pair visited was between US$12.60 and US$19.50, and the incremental cost per additional facility-based delivery ranged from US$85.50 to US$137.20 for financial and economic costs (with household costs). Three scale-up scenarios were considered, with the financial cost per home visit respectively varying from $1.44 to $3.21 across scenarios. Cost-effectiveness compares well with supply-side initiatives to increase coverage of facility-based deliveries, and the intervention would benefit from substantial economies of scale.
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Affiliation(s)
- Fatuma Manzi
- Ifakara Health Institute, Dar Es Salaam, P.O. Box 78 373, Tanzania
| | - Emmanuelle Daviaud
- Medical Research Council, Francie van Zijl Drive, Parowvallei, Cape; PO Box 19070 7505 Tygerberg, Cape Town, South Africa
| | - Joanna Schellenberg
- London School of Hygiene & Tropical Medicine, Keppel Street London WC1E 7HT, London, UK
| | - Joy E Lawn
- London School of Hygiene & Tropical Medicine, Keppel Street London WC1E 7HT, London, UK
| | - Theopista John
- World Health Organisation, Dar Es Salaam, United Republic of Tanzania, Tanzania
| | - Georgina Msemo
- Ministry of Health and Social Welfare, Sokoine Drive, Dar Es Salaam, Tanzania
| | - Helen Owen
- London School of Hygiene & Tropical Medicine, Keppel Street London WC1E 7HT, London, UK
| | - Diana Barger
- Save the Children, 899 North Capitol Street, Suite 900, Washington, DC 20002
| | - Claudia Hanson
- London School of Hygiene & Tropical Medicine, Keppel Street London WC1E 7HT, London, UK
| | - Josephine Borghi
- London School of Hygiene & Tropical Medicine, Keppel Street London WC1E 7HT, London, UK
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Zeng W, Li G, Ahn H, Nguyen HTH, Shepard DS, Nair D. Cost-effectiveness of health systems strengthening interventions in improving maternal and child health in low- and middle-income countries: a systematic review. Health Policy Plan 2017; 33:283-297. [DOI: 10.1093/heapol/czx172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 01/17/2023] Open
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Hunter BM, Murray SF. Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes? BMC Pregnancy Childbirth 2017; 17:262. [PMID: 28854877 PMCID: PMC5577737 DOI: 10.1186/s12884-017-1445-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 08/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Demand-side financing (DSF) interventions, including cash transfers and vouchers, have been introduced to promote maternal and newborn health in a range of low- and middle-income countries. These interventions vary in design but have typically been used to increase health service utilisation by offsetting some financial costs for users, or increasing household income and incentivising 'healthy behaviours'. This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health. METHODS A secondary analysis (using an adapted Supporting the Use of Research Evidence framework - SURE) was performed on studies that had previously been identified in a systematic review of evidence on DSF interventions in maternal and newborn health. RESULTS The article draws on findings from 49 quantitative and 49 qualitative studies. The studies give insights on difficulties with exclusion of migrants, young and multiparous women, with demands for informal fees at facilities, and with challenges maintaining quality of care under increasing demand. Schemes experienced difficulties if communities faced long distances to reach participating facilities and poor access to transport, and where there was inadequate health infrastructure and human resources, shortages of medicines and problems with corruption. Studies that documented improved care-seeking indicated the importance of adequate programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements) to address the issue of concern, concurrent investments in supply-side capacity to sustain and/or improve quality of care, and awareness generation using community-based workers, leaders and women's groups. CONCLUSIONS Evaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social, geographical and health systems factors as barriers to accessing care. Careful design of DSF programmes as part of broader maternal and newborn health initiatives would need to take into account these barriers, the behaviours of staff and the quality of care in health facilities. Research is still needed on the policy context for DSF schemes in order to understand how they become sustainable and where they fit, or do not fit, with plans to achieve equitable universal health coverage.
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Affiliation(s)
- Benjamin M. Hunter
- King’s College London, Department of International Development, The Strand, London, WC2R 2LS UK
| | - Susan F. Murray
- King’s College London, Department of International Development, The Strand, London, WC2R 2LS UK
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Goodman DM, Ramaswamy R, Jeuland M, Srofenyoh EK, Engmann CM, Olufolabi AJ, Owen MD. The cost effectiveness of a quality improvement program to reduce maternal and fetal mortality in a regional referral hospital in Accra, Ghana. PLoS One 2017; 12:e0180929. [PMID: 28708899 PMCID: PMC5510839 DOI: 10.1371/journal.pone.0180929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 06/25/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of a quality improvement intervention aimed at reducing maternal and fetal mortality in Accra, Ghana. DESIGN Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis. METHODS Data were collected on the cost and outcomes of a 5-year Kybele-Ghana Health Service Quality Improvement (QI) intervention conducted at Ridge Regional Hospital, a tertiary referral center in Accra, Ghana, focused on systems, personnel, and communication. Maternal deaths prevented were estimated comparing observed rates with counterfactual projections of maternal mortality and case-fatality rates for hypertensive disorders of pregnancy and obstetric hemorrhage. Stillbirths prevented were estimated based on counterfactual estimates of stillbirth rates. Cost-effectiveness was then calculated using estimated disability-adjusted life years averted and subjected to Monte Carlo and one-way sensitivity analyses to test the importance of assumptions inherent in the calculations. MAIN OUTCOME MEASURE Incremental Cost-effectiveness ratio (ICER), which represents the cost per disability-adjusted life-year (DALY) averted by the intervention compared to a model counterfactual. RESULTS From 2007-2011, 39,234 deliveries were affected by the QI intervention implemented at Ridge Regional Hospital. The total budget for the program was $2,363,100. Based on program estimates, 236 (±5) maternal deaths and 129 (±13) intrapartum stillbirths were averted (14,876 DALYs), implying an ICER of $158 ($129-$195) USD. This value is well below the highly cost-effective threshold of $1268 USD. Sensitivity analysis considered DALY calculation methods, and yearly prevalence of risk factors and case fatality rates. In each of these analyses, the program remained highly cost-effective with an ICER ranging from $97-$218. CONCLUSION QI interventions to reduce maternal and fetal mortality in low resource settings can be highly cost effective. Cost-effectiveness analysis is feasible and should regularly be conducted to encourage fiscal responsibility in the pursuit of improved maternal and child health.
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Affiliation(s)
- David M. Goodman
- Hubert-Yeargan Center for Global Health, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America
- * E-mail:
| | - Rohit Ramaswamy
- Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Marc Jeuland
- Sanford School of Public Policy & Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | | | - Cyril M. Engmann
- Department of Pediatrics, University of Washington & Seattle Children’s Hospital, Seattle, WA, United States of America
| | - Adeyemi J. Olufolabi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States of America
| | - Medge D. Owen
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
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Hunter BM, Harrison S, Portela A, Bick D. The effects of cash transfers and vouchers on the use and quality of maternity care services: A systematic review. PLoS One 2017; 12:e0173068. [PMID: 28328940 PMCID: PMC5362260 DOI: 10.1371/journal.pone.0173068] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/14/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cash transfers and vouchers are forms of 'demand-side financing' that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years. METHODS This systematic review consolidates evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, and updates the systematic searches to June 2015 using the Joanna Briggs Institute approach for systematic reviewing. The review protocol for this update was registered with PROSPERO (CRD42015020637). RESULTS Data from 51 studies (15 more than previous reviews) and 22 cash transfer and voucher programmes suggest that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant. However, effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment. There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes. CONCLUSION Future research should use multiple intervention arms to compare cost-effectiveness with similar investment in public services, and should look beyond short- to medium-term service utilisation by examining programme costs, longer-term effects on service utilisation and health outcomes, and the equity of those effects.
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Affiliation(s)
- Benjamin M. Hunter
- Department of International Development, King’s College London, London, United Kingdom
| | - Sean Harrison
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Debra Bick
- Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, United Kingdom
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Borghi J, Little R, Binyaruka P, Patouillard E, Kuwawenaruwa A. In Tanzania, the many costs of pay-for-performance leave open to debate whether the strategy is cost-effective. Health Aff (Millwood) 2016; 34:406-14. [PMID: 25732490 DOI: 10.1377/hlthaff.2014.0608] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Pay-for-performance programs in health care are widespread in low- and middle-income countries. However, there are no studies of these programs' costs or cost-effectiveness. We conducted a cost-effectiveness analysis of a pay-for-performance pilot program in Tanzania and modeled costs of its national expansion. We reviewed project accounts and reports, interviewed key stakeholders, and derived outcomes from a controlled before-and-after study. In 2012 US dollars, the financial cost of the pay-for-performance pilot was $1.2 million, and the economic cost was $2.3 million. The incremental cost per additional facility-based birth ranged from $540 to $907 in the pilot and from $94 to $261 for a national program. In a low-income setting, the costs of managing the program and generating and verifying performance data were substantial. Pay-for-performance programs can stimulate the generation and use of health information by health workers and managers for strategic planning purposes, but the time involved could divert attention from service delivery. Pay-for-performance programs may become more cost-effective when integrated into routine systems over time.
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Affiliation(s)
- Josephine Borghi
- Josephine Borghi is a senior lecturer in the Department of Global Health and Development, London School of Hygiene and Tropical Medicine
| | - Richard Little
- Richard Little is a consultant health economist in Cambridge, England
| | - Peter Binyaruka
- Peter Binyaruka is a research scientist at the Ifakara Health Institute
| | - Edith Patouillard
- Edith Patouillard is a senior scientific collaborator in the Epidemiology and Public Health Department, Health Intervention Unit, Swiss Tropical and Public Health Institute, in Basel; the University of Basel; and the World Health Organization Global Malaria Programme, in Geneva, Switzerland
| | - August Kuwawenaruwa
- August Kuwawenaruwa is a research scientist at the Ifakara Health Institute, in Dar es Salaam, Tanzania
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Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. LANCET GLOBAL HEALTH 2016; 4:e845-e855. [DOI: 10.1016/s2214-109x(16)30180-2] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/23/2016] [Accepted: 07/20/2016] [Indexed: 01/22/2023]
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Wekesah FM, Mbada CE, Muula AS, Kabiru CW, Muthuri SK, Izugbara CO. Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review. Syst Rev 2016; 5:137. [PMID: 27526773 PMCID: PMC4986260 DOI: 10.1186/s13643-016-0305-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/20/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Many interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA. METHODS African Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability). RESULTS Seventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess. CONCLUSIONS Many non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023750.
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Affiliation(s)
- Frederick M. Wekesah
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Julius Global Health, Julius Center for Health Sciences and Primary Care, Utrecht Medical Center, Utrecht Huispost Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, Netherlands
| | - Chidozie E. Mbada
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Department of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Health, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre, Malawi
- African Center for Public Health and Herbal Medicine, University of Malawi, Blantyre, Malawi
| | - Caroline W. Kabiru
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Stella K. Muthuri
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Chimaraoke O. Izugbara
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
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Montagu D, Goodman C, Berman P, Penn A, Visconti A. Recent trends in working with the private sector to improve basic healthcare: a review of evidence and interventions. Health Policy Plan 2016; 31:1117-32. [PMID: 27198979 DOI: 10.1093/heapol/czw018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2016] [Indexed: 11/14/2022] Open
Abstract
The private sector provides the majority of health care in Africa and Asia. A number of interventions have, for many years, applied different models of subsidy, support and engagement to address social and efficiency failures in private health care markets. We have conducted a review of these models, and the evidence in support of them, to better understand what interventions are currently common, and to what extent practice is based on evidence. Using established typologies, we examined five models of intervention with private markets for care: commodity social marketing, social franchising, contracting, accreditation and vouchers. We conducted a systematic review of both published and grey literature, identifying programmes large enough to be cited in publications, and studies of the listed intervention types. 343 studies were included in the review, including both published and grey literature. Three hundred and eighty programmes were identified, the earliest having begun operation in 1955. Commodity social marketing programmes were the most common intervention type, with 110 documented programmes operating for condoms alone at the highest period. Existing evidence shows that these models can improve access and utilization, and possibly quality, but for all programme types, the overall evidence base remains weak, with practice in private sector engagement consistently moving in advance of evidence. Future research should address key questions concerning the impact of interventions on the market as a whole, the distribution of benefits by socio-economic status, the potential for scale up and sustainability, cost-effectiveness compared to relevant alternatives and the risk of unintended consequences. Alongside better data, a stronger conceptual basis linking programme design and outcomes to context is also required.
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Affiliation(s)
| | | | | | - Amy Penn
- University of California, San Francisco, CA, USA
| | - Adam Visconti
- Georgetown University, Washington, DC, USA Providence Hospital, Mobile, AL, USA
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Mehta KM, Rerolle F, Rammohan SV, Albohm DC, Muwowo G, Moseson H, Sept L, Lee HL, Bendavid E. Systematic Motorcycle Management and Health Care Delivery: A Field Trial. Am J Public Health 2015; 106:87-94. [PMID: 26562131 DOI: 10.2105/ajph.2015.302891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We investigated whether managed transportation improves outreach-based health service delivery to rural village populations. METHODS We examined systematic transportation management in a small-cluster interrupted time series field trial. In 8 districts in Southern Zambia, we followed health workers at 116 health facilities from September 2011 to March 2014. The primary outcome was the average number of outreach trips per health worker per week. Secondary outcomes were health worker productivity, motorcycle performance, and geographical coverage. RESULTS Systematic fleet management resulted in an increase of 0.9 (SD = 1.0) trips to rural villages per health worker per week (P < .001), village-level health worker productivity by 20.5 (SD = 5.9) patient visits, 10.2 (SD = 1.5) measles immunizations, and 5.2 (SD = 5.4) child growth assessments per health worker per week. Motorcycle uptime increased by 3.5 days per week (P < .001), use by 1.5 days per week (P < .001), and mean distance by 9.3 kilometers per trip (P < .001). Geographical coverage of health outreach increased in experimental (P < .001) but not control districts. CONCLUSIONS Systematic motorcycle management improves basic health care delivery to rural villages in resource-poor environments through increased health worker productivity and greater geographical coverage.
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Affiliation(s)
- Kala M Mehta
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
| | - Francois Rerolle
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
| | - Sonali V Rammohan
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
| | - Davis C Albohm
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
| | - George Muwowo
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
| | - Heidi Moseson
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
| | - Lesley Sept
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
| | - Hau L Lee
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
| | - Eran Bendavid
- Kala M. Mehta, Sonali V. Rammohan, and Hau L. Lee are with the Value Chain Innovation Initiative, Stanford Graduate School of Business, Stanford University, Stanford, CA. Francois Rerolle was with the Department of Civil and Environmental Engineering, Stanford University. Davis C. Albohm and Lesley Sept are with the Stanford Institute for Innovation in Developing Economies, Stanford University. George Muwowo was with the Stanford Graduate School of Business Field Office, Riders for Health Evaluation Program, Livingstone, Zambia. Kala M. Mehta and Heidi Moseson are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Eran Bendavid is with the Department of General Medical Disciplines, Stanford University School, of Medicine Stanford
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Borghi J, Ramsey K, Kuwawenaruwa A, Baraka J, Patouillard E, Bellows B, Binyaruka P, Manzi F. Protocol for the evaluation of a free health insurance card scheme for poor pregnant women in Mbeya region in Tanzania: a controlled-before and after study. BMC Health Serv Res 2015; 15:258. [PMID: 26141724 PMCID: PMC4490646 DOI: 10.1186/s12913-015-0905-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 06/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of demand-side financing mechanisms to increase health service utilisation among target groups and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is limited evidence on the effects of such schemes on equity, financial protection, quality of care, and cost-effectiveness. A scheme providing free health insurance cards to poor pregnant women and their households was first introduced in two regions of Tanzania in 2011 and gradually expanded in 2012. METHODS A controlled before and after study will examine in one district the effect of the scheme on utilization, quality, and cost of healthcare services accessed by poor pregnant women and their households in Tanzania. Data will be collected 4 months before implementation of the scheme and 17 months after the start of implementation from a survey of 24 health facilities, 288 patients exiting consultations and 1500 households of women who delivered in the previous year in one intervention district (Mbarali). 288 observations of provider-client interactions will also be carried out. The same data will be collected from a comparison district in a nearby region. A process evaluation will ascertain how the scheme is implemented in practice and the level of implementation fidelity and potential moderators. The process evaluation will draw from impact evaluation data and from three rounds of data collection at the national, regional, district, facility and community levels. An economic evaluation will measure the cost-effectiveness of the scheme relative to current practice from a societal perspective. DISCUSSION This evaluation will generate evidence on the impact and cost-effectiveness of targeted health insurance for pregnant women in a low income setting, as well as building a better understanding of the implementation process and challenges for programs of this nature.
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Affiliation(s)
- Josephine Borghi
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania. .,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Kate Ramsey
- Columbia University, Mailman School of Public Health, New York, NY, USA
| | | | - Jitihada Baraka
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania
| | - Edith Patouillard
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | | | - Peter Binyaruka
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania
| | - Fatuma Manzi
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania
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Vouchers for family planning and sexual and reproductive health services: a review of voucher programs involving Marie Stopes International among 11 Asian and African countries. Int J Gynaecol Obstet 2015; 130 Suppl 3:E15-20. [PMID: 26165906 DOI: 10.1016/j.ijgo.2015.06.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate provision of vouchers for family planning and sexual and reproductive health (SRH) services. METHODS A review was conducted to assess the effects of 24 voucher programs in Marie Stopes International programs across 11 countries in Asia and Africa between 2005 and the present. The outcome measures were uptake of services; service use among specific subgroups; user satisfaction with service quality; and efficiency of service delivery. RESULTS Twelve of the 24 programs covered family planning only, whereas the other 12 programs covered family planning and/or SRH. Service uptake increased following implementation, although voucher redemption rates varied by program (44.1%-92.4%). Most programs were successful in reaching subgroups, such as the poor and young (under 25years), although this outcome depended on the targeting approach. Most programs recorded high user satisfaction; however, the evidence regarding efficiency was mixed. CONCLUSIONS Vouchers increased uptake of services and, in some cases, improved service quality and reach to specific groups. Nevertheless, robust evaluation designs are required to measure efficiency.
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Alam N, Hajizadeh M, Dumont A, Fournier P. Inequalities in maternal health care utilization in sub-Saharan African countries: a multiyear and multi-country analysis. PLoS One 2015; 10:e0120922. [PMID: 25853423 PMCID: PMC4390337 DOI: 10.1371/journal.pone.0120922] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/27/2015] [Indexed: 11/28/2022] Open
Abstract
To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.
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Affiliation(s)
- Nazmul Alam
- Research Centre of the University of Montreal Hospital (CR-CHUM), Montreal, Quebec, Canada
- School of Public Health, University of Montreal, Montreal, Canada
- * E-mail:
| | | | - Alexandre Dumont
- Research Institute for Development, Université Paris Descartes, Paris, France
| | - Pierre Fournier
- Research Centre of the University of Montreal Hospital (CR-CHUM), Montreal, Quebec, Canada
- School of Public Health, University of Montreal, Montreal, Canada
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Sen G, Govender V. Sexual and reproductive health and rights in changing health systems. Glob Public Health 2014; 10:228-42. [PMID: 25536851 PMCID: PMC4318007 DOI: 10.1080/17441692.2014.986161] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 11/06/2014] [Indexed: 11/17/2022]
Abstract
Sexual and reproductive health and rights (SRHR) are centrally important to health. However, there have been significant shortcomings in implementing SRHR to date. In the context of health systems reform and universal health coverage/care (UHC), this paper explores the following questions. What do these changes in health systems thinking mean for SRHR and gender equity in health in the context of renewed calls for increased investments in the health of women and girls? Can SRHR be integrated usefully into the call for UHC, and if so how? Can health systems reforms address the continuing sexual and reproductive ill health and violations of sexual and reproductive rights (SRR)? Conversely, can the attention to individual human rights that is intrinsic to the SRHR agenda and its continuing concerns about equality, quality and accountability provide impetus for strengthening the health system? The paper argues that achieving equity on the UHC path will require a combination of system improvements and services that benefit all, together with special attention to those whose needs are great and who are likely to fall behind in the politics of choice and voice (i.e., progressive universalism paying particular attention to gender inequalities).
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Affiliation(s)
- Gita Sen
- Ramalingaswami Centre on Equity and Social Determinants of Health, Public Health Foundation of India, Bangalore, India
| | - Veloshnee Govender
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Incremental cost of increasing access to maternal health care services: perspectives from a demand and supply side intervention in Eastern Uganda. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2014; 12:14. [PMID: 24976793 PMCID: PMC4074383 DOI: 10.1186/1478-7547-12-14] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 06/09/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction High maternal and infant mortality continue to be major challenges to the attainment of the Millennium Development Goals for many low and middle-income countries. There is now evidence that voucher initiatives can increase access to maternal health services. However, a dearth of knowledge exists on the cost implications of voucher schemes. This paper estimates the incremental costs of a demand and supply side intervention aimed at increasing access to maternal health care services. Methods This costing study was part of a quasi-experimental voucher study conducted in two districts in Eastern Uganda to explore the impact of demand and supply - side incentives on increasing access to maternal health services. The provider’s perspective was used and the ingredients approach to costing was employed. Costs were based on market prices as recorded in program records. Total, unit, and incremental costs were calculated. Results The estimated total financial cost of the intervention for the one year of implementation was US$525,472 (US$1 = 2200UgShs). The major cost drivers included costs for transport vouchers (35.3%), health system strengthening (29.2%) and vouchers for maternal health services (18.2%). The average cost of transport per woman to and from the health facility was US$4.6. The total incremental costs incurred on deliveries (excluding caesarean section) was US$317,157 and US$107,890 for post natal care (PNC). The incremental costs per additional delivery and PNC attendance were US$23.9 and US$7.6 respectively. Conclusion Subsidizing maternal health care costs through demand and supply – side initiatives may not require significant amounts of resources contrary to what would be expected. With Uganda’s Gross Domestic Product (GDP) per capita of US$55` (2012), the incremental cost per additional delivery (US$23.9) represents about 5% of GDP per capita to save a mother and probably her new born. For many low income countries, this may not be affordable, yet reliance on donor funding is often not sustainable. Alternative ways of raising additional resources for health must be explored. These include; encouraging private investments in critical sectors such as rural transport, health service provision; mobilizing households to save financial resources for preparedness, and financial targeting for the most vulnerable.
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