Activity-based costing of health-care delivery, Haiti

Costing of Health and Wellness Centres: A Case Study of Gujarat

The National Health Policy 2017 recommended the establishment of health and wellness centres (HWC) as the primary platform to deliver comprehensive primary health care in India and emphasised that about two-thirds of the health budget of the government should be invested on primary care. In February 2018, the government announced its plan to create 150,000 HWCs under the Ayushman Bharat initiative by transforming the already existing sub-centres (SCs), primary health centres (PHCs) and urban PHCs as HWCs by 2022. The operationalisation of HWCs has been planned in a phased manner. However, for scaling up and replicability, it is imperative for the government to know how much to budget for this initiative, so that there are no interruptions in the smooth flow of services. Taking Gujarat as a case study, the study took a sample of eight HWCs for estimating the total and per-unit costs for each type of HWC. OPD footfalls were taken as an indicator for measuring output. The incremental unit costs were estimated by calculating the difference between the pre and post-conversion unit costs, in order to understand the cost implications of the conversion. The study also estimated the possible total costs in relation to the health budget of the state to understand the financial implications of scaling up HWCs. The results indicated that though the costs have gone up after conversion, outpatient department (OPD) footfalls have also increased at all facilities, but most significantly for the SCs, resulting in costs per OPD footfalls coming down significantly. For nearly all the centres, there has been a fall in the incremental costs per OPD visits indicating that the conversion to HWC has been quite economical. It was estimated that a total of about ₹7.13 billion will be spent on running 1,500 HWCs in the year 2020–2021, though, the incremental costs of scaling up would be significantly less at about ₹940 million. If, however, the entire gamut of services envisaged to be a part of the HWC initiative are added, the costs are likely to increase. More research with additional data points would be required to confirm these tentative findings, but the results could be used as a baseline for future such studies.

Comparing the average cost of outpatient care of public and for-profit private providers in India

Introduction

Understanding the cost of care associated with different kinds of healthcare providers is necessary for informing the policy debates in mixed health-systems like India’s. Existing studies reporting Out of Pocket Expenditure (OOPE) per episode of outpatient care in public and private providers in India do not provide a fair comparison because they have not taken into account the government subsidies received by public facilities. Public and private health insurance in India do not cover outpatient care and for-profit providers have to meet all their costs out of the payments they take from patients.

Methods

The average direct cost per acute episode of outpatient care was compared for public providers, for-profit formal providers and informal private providers in Chhattisgarh state of India. For public facilities, government subsidies for various inputs were taken into account. Resources used were apportioned using Activity Based Costing. Land provided free to public facilities was counted at market prices. The study used two datasets: a) household survey on outpatient utilisation and OOPE b) facility survey of public providers to find the input costs borne by government per outpatient-episode.

Results

The average cost per episode of outpatient care was Indian Rupees (INR) 400 for public providers, INR 586 for informal private providers and INR 2643 for formal for-profit providers and they managed 39.3, 37.9 and 22.9% of episodes respectively. The average cost for government and households put together was greater for using formal for-profit providers than the public providers. The disease profile of care handled by different types of providers was similar. Volume of patients and human-resources were key cost drivers in public facilities. Close to community providers involved less cost than others.

Conclusions and recommendations

The findings have implications for the desired mix of public and private providers in India’s health-system. Poor regulation of for-profit providers was an important structural cost driver. Purchasing outpatient care from private providers may not reduce average cost. Policies to strengthen public provisioning of curative primary care close to communities can help in reducing cost.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06777-7.

Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program

Clinic-based social needs screening has been associated with increased access to social services and improved health outcomes. Using a pragmatic study design in an urban pediatric practice, we used logistic regression to identify factors associated with successful social service uptake. From December 2017 to November 2018, 4948 households were screened for social needs, and 20% self-reported at least one. Of the 287 households with unmet needs who were referred and interested in further assistance, 43% reported successful social service uptake. Greater than 4 outreach encounters (adjusted odds ratio = 1.92; 95% confidence interval = 1.06-3.49) and follow-up time >30 days (adjusted odds ratio = 0.43; 95% confidence interval = 0.25-0.73) were significantly associated with successful referrals. These findings have implementation implications for programs aiming to address social needs in practice. Less than half of households reported successful referrals, which suggests the need for additional research and an opportunity for further program optimization.

Moving Towards Universal Health Coverage in Haiti

Haiti announced in 2018 its aim to achieve universal health coverage. In this paper, we discuss what this objective means for the country and what next steps should be taken. To contextualize the notion, we framed Haiti en route to the 2030 goal and analyzed qualitatively the status quo in terms of geographic, financial, and service access. For each dimension, we focused on the context, the government's policies and political agendas, their implementation progress, and key influential factors. Our analysis found little progress and numerous challenges. Geographic access was limited due principally to the insufficient number of facilities, difficulties in reaching health facilities, and local customs. Financial coverage was low because of the government's insufficient budgets, inefficient budget allocation, and ineffective management. Service access also had room for significant improvement for a lack of basic infrastructure and resources, gaps between the essential service package guidelines, health professionals' skills, and the needs, as well as deficiencies in people-centered care. These factors affected not only health service coverage but also its quality. We found that the root causes of these issues were composed of unstable financing mechanisms, opportunistic resource allocation, and ineffective management control systems. We suggest that to overcome these issues and achieve universal health coverage with decent service quality, Haiti's health system needs to be reformed by implementing strategic financing, decentralized management systems, and community engagement in primary health care.