An assessment of the performance of the national health research system in Mauritius.

BACKGROUND: The goal of universal health coverage (UHC) is that every individual has access to high-quality health services without running the consequences of financial hardship. The World health report 2013 "Research for universal health coverage" states a performant National Health Research Systems (NHRS) can contribute by providing solutions to challenges encountered in advancing towards UHC by 2030. Pang et al. define a NHRS as the people, institutions, and activities whose primary aim is to generate and promote utilization of high-quality knowledge that can be used to promote, restore, and/or maintain the health status of populations. The WHO Regional Committee for Africa (RC) adopted a resolution in 2015 urging member states to strengthen their NHRS to facilitate production and utilization of evidence in policy development, planning, product development, innovation, and decision-making. This study aimed to calculate NHRS barometer scores for Mauritius in 2020, identify the gaps in NHRS performance, and recommend interventions for boosting the Mauritius NHRS in the pursuit of UHC. METHODS: The study used a cross-sectional survey design. A semi-structured NHRS questionnaire was administered and complemented with a review of documents archived in pertinent Mauritius Government Ministries, universities, research-oriented departments, and non-governmental organizations websites. The African NHRS barometer developed in 2016 for countries to monitor the RC resolution implementation was applied. The barometer consists of four NHRS functions (leadership and governance, developing and sustaining resources, producing and utilizing research, financing research for health [R4H]), and 17 sub-functions, e.g., existence of a national policy on research for health (R4H), presence of a Mauritius Research and Innovation Council (MRIC), existence of knowledge translation platform. RESULTS: In 2020, Mauritius had an overall average NHRS barometer score of 60.84%. The four NHRS functions average indices were 50.0% for leadership and governance, 77.0% for developing and sustaining resources, 52.0% for producing and utilizing R4H, and 58.2% for financing R4H. CONCLUSION: The performance of NHRS could be improved through the development of a national R4H policy, strategic plan, prioritized agenda, and national multi-stakeholder health research management forum. Furthermore, increased funding for the NHRS may nurture the human resources for health research capacities, hence the number of pertinent publications and health innovations.

Re-analyzing the SARS-CoV-2 series using an extended integer-valued time series models: A situational assessment of the COVID-19 in Mauritius.

This paper proposes some high-ordered integer-valued auto-regressive time series process of order p (INAR(p)) with Zero-Inflated and Poisson-mixtures innovation distributions, wherein the predictor functions in these mentioned distributions allow for covariate specification, in particular, time-dependent covariates. The proposed time series structures are tested suitable to model the SARs-CoV-2 series in Mauritius which demonstrates excess zeros and hence significant over-dispersion with non-stationary trend. In addition, the INAR models allow the assessment of possible causes of COVID-19 in Mauritius. The results illustrate that the event of Vaccination and COVID-19 Stringency index are the most influential factors that can reduce the locally acquired COVID-19 cases and ultimately, the associated death cases. Moreover, the INAR(7) with Zero-inflated Negative Binomial innovations provides the best fitting and reliable Root Mean Square Errors, based on some short term forecasts. Undeniably, these information will hugely be useful to Mauritian authorities for implementation of comprehensive policies.

The Discounted Money Value of Human Life Losses Associated With COVID-19 in Mauritius.

Background: Mauritius along with other 12 countries in the African Region was identified at the early start of the COVID-19 pandemic as being at high risk due to high volume of international travel, high prevalence of non-communicable diseases and co-morbidities, high population density and significant share of population over 60 years (16%). The objective of this study was to estimate the total discounted money value of human life losses (TDMVCLMAURITIUS ) associated with COVID-19 in Mauritius. Methods: The human capital approach (HCA) was used to estimate the TDMVCLMAURITIUS of the 10 human life losses linked with COVID-19 in Mauritius as of 16 October 2020. The HCA model was estimated with the national life expectancy of 75.51 years and a discount rate of 3%. A sensitivity analysis was performed assuming (a) 5 and 10% discount rates, and (b) the average world life expectancy of 73.2 years, and the world highest life expectancy of 88.17 years. Results: The money value of human lives lost to COVID-19, at a discounted rate of 3%, had an estimated TDMVCLMAURITIUS of Int$ 3,120,689, and an average of Int$ 312,069 per human life lost. Approximately 74% of the TDMVCLMAURITIUS accrued to persons aged between 20 and 59 years. Reanalysis of the model with 5 and 10% discount rates, holding national life expectancy constant, reduced the TDMVCLMAURITIUS by 19.0 and 45.5%, respectively. Application of the average world life expectancy at 3% discount rate reduced TDMVCLMAURITIUS by 13%; and use of the world highest life expectancy at 3% discount rate increased TDMVCLMAURITIUS by 50%. Conclusions: The average discounted money value per human life loss associated with COVID-19 is 12-fold the per capita GDP for Mauritius. All measures implemented to prevent widespread community transmission of COVID-19 may have saved the country 837 human lives worth Int$258,080,991. This evidence, conjointly with human rights arguments, calls for increased investments to bridge the existing gaps for achieving universal health coverage by 2030.

Assessing health system challenges and opportunities for better noncommunicable disease outcomes: the case of Mauritius.

BACKGROUND: The objectives of the study reported in this paper were: (a) to score the coverage of core NCD population-based interventions and individual services in Mauritius; (b) to analyse and score the presence of 15 common health system challenges that impede delivery of core NCD interventions and services in Mauritius; and (c) to provide policy recommendations for Mauritius to address health system barriers to delivery of NCD interventions and services. METHODS: The Mauritius country assessment applied the guidelines developed by the World Health Organization Regional Office for Europe for systematically scoring coverage of NCD interventions and assessing health system challenges for improving NCD outcomes. The assessment used qualitative research design approach. RESULTS: Of the 24 core population-based interventions for addressing key NCD risk factors, 16.7% were rated extensive, 37.5% moderate and 45.8% limited. Three (20%), 8 (53%) and 4 (27%) of the 15 individual/personal CVD, diabetes and cancer services were rated extensive, moderate and limited respectively. The top five health system challenges hampering scale-up of coverage of population-based NCD interventions in Mauritius were inadequate interagency cooperation; limited application of explicit priority setting approaches; inadequate change management; sub-optimal distribution and mix human resources; insufficient population empowerment; and insufficient political commitment. The top five challenges had average scores of between 3.1 (interagency cooperation) and 2.4 (distribution and mix of human resources). The top five health system challenges constraining expansion in coverage of individual NCD services were limited integration of evidence into practice; limited use of explicit priority-setting approaches; inadequate application of information and technology solutions; insufficient population empowerment; and sub-optimal distribution and mix of human resources. The top five challenges for individual interventions had mean scores varying between 2.6 (integration of evidence into practice) and 1.7 (distribution and mix of human resources). CONCLUSIONS: Mauritius needs to increase its domestic general government investments into the national health system and requisite multi-sectoral action to address the priority health system challenges with a view of bridging the existing gaps in coverage of NCD population-based interventions and individual services.

Blood Safety Status in WHO African Region Countries: Lessons Learnt from Mauritius.

In 2001, the WHO Office for Africa adopted a strategy for blood safety defining four targets. This paper describes the progress made by Mauritius in the implementation of this strategy. The blood safety indicators were collected and compared with the norms recommended by WHO. The country has formulated its blood policy and developed a strategic plan for its implementation since 2004. The total number of blood donations increased from 31,228 in 2002 to 43,742 in 2016, giving an annual blood collection rate evolving from 26.3 per 1000 inhabitants in 2002 to 34.2 per 1000 inhabitants in 2016. The percentage of voluntary donations rose from 60% to 82.5%. Since 2002, all the blood units collected have been tested for the mandatory infectious markers. The Blood Transfusion Service has been certified ISO2008-9001 and nucleic acid testing has been introduced. The preparation of blood components increased from 60% to 98.2%. The most transfused blood components were red cell concentrates, platelet concentrates, and fresh frozen plasma. In addition to transfusion activities, there were other departments performing antenatal serology, tissue typing, special investigations, and reagent preparation. Despite the progress made, some challenges remain, namely, legal framework and haemovigilance system. A regulatory system for blood needs to be established.

Health care seeking patterns and determinants of out-of-pocket expenditure for malaria for the children under-five in Uganda.

BACKGROUND: The objectives of this study were to assess the patterns of treatment seeking behaviour for children under five with malaria; and to examine the statistical relationship between out-of-pocket expenditure (OOP) on malaria treatment for under-fives and source of treatment, place of residence, education and wealth characteristics of Uganda households. OOP expenditure on health care is now a development concern due to its negative effect on households' ability to finance consumption of other basic needs. METHODS: The 2009 Uganda Malaria Indicator Survey was the source of data on treatment seeking behaviour for under-five children with malaria, and patterns and levels of OOP expenditure for malaria treatment. Binomial logit and Log-lin regression models were estimated. In logit model the dependent variable was a dummy (1=incurred some OOP, 0=none incurred) and independent variables were wealth quintiles, rural versus urban, place of treatment, education level, sub-region, and normal duty disruption. The dependent variable in Log-lin model was natural logarithm of OOP and the independent variables were the same as mentioned above. RESULTS: Five key descriptive analysis findings emerge. First, malaria is quite prevalent at 44.7% among children below the age of five. Second, a significant proportion seeks treatment (81.8%). Third, private providers are the preferred option for the under-fives for the treatment of malaria. Fourth, the majority pay about 70.9% for either consultation, medicines, transport or hospitalization but the biggest percent of those who pay, do so for medicines (54.0%). Fifth, hospitalization is the most expensive at an average expenditure of US$7.6 per child, even though only 2.9% of those that seek treatment are hospitalized.The binomial logit model slope coefficients for the variables richest wealth quintile, Private facility as first source of treatment, and sub-regions Central 2, East central, Mid-eastern, Mid-western, and Normal duties disrupted were positive and statistically significant at 99% level of confidence. On the other hand, the Log-lin model slope coefficients for Traditional healer, Sought treatment from one source, Primary educational level, North East, Mid Northern and West Nile variables had a negative sign and were statistically significant at 95% level of confidence. CONCLUSION: The fact that OOP expenditure is still prevalent and private provider is the preferred choice, increasing public provision may not be the sole answer. Plans to improve malaria treatment should explicitly incorporate efforts to protect households from high OOP expenditures. This calls for provision of subsidies to enable the private sector to reduce prices, regulation of prices of malaria medicines, and reduction/removal of import duties on such medicines.

Spirometric reference values for an East-African population.

BACKGROUND: Accurate interpretation of lung function testing requires appropriate reference values. Unfortunately, few African countries have produced spirometric reference values for their populations. OBJECTIVES: The present study was carried out in order to establish normal lung function values for subjects living in Rwanda, East Africa. METHODS: The study was conducted in Kigali, capital of Rwanda, and in the rural district of Huye in southern Rwanda. The variables studied were forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and peak expiratory flow. Multiple regression analysis was performed using age, height, weight and BMI as independent variables to obtain predicted equations for both sexes. RESULTS: Predicted equations for normal lung functions were obtained from 740 healthy nonsmoking subjects; 394 were females and 346 were males. Minor differences in FEV1 and FVC were observed in comparison with other studies of Africans, African-Americans (difference in FEV1 and FVC of less than 5%), Chinese and Indians. When compared with selected studies from Caucasians and white Americans, our results for FEV1 and FVC were 9-12% and 16-18% lower in men and 12-23% and 17-28% lower in women, respectively. CONCLUSIONS: This study provides reference values for pulmonary function in a healthy, nonsmoking Rwandan population and enables comparisons to be made with other prediction equations from other populations. Spirometric reference values in our study were similar to those obtained in a study of black Americans by Hankinson et al.

Moving from ideas to action - developing health financing systems towards universal coverage in Africa.

BACKGROUND: Accelerating progress towards universal coverage in African countries calls for concrete actions that reinforce social health protection through establishment of sustainable health financing mechanisms. In order to explore possible pathways for moving past the existing obstacles, panel discussions were organized on health financing bringing together Ministers of health and Ministers of finance with the objective of creating a discussion space where the different perspectives on key issues and needed actions could meet. This article presents a synthesis of panel discussions focusing on the identified challenges and the possible solutions. The overview of this paper is based on the objectives and proceedings of the panel discussions and relies on the observation and study of the interaction between the panelists and on the discourse used. SUMMARY: The discussion highlighted that a large proportion of the African population has no access to needed health services with significant reliance on direct out of pocket payments. There are multiple obstacles in making prepayment and pooling mechanisms operational. The relatively strong political commitment to health has not always translated into more public spending for health. Donor investment in health in low income countries still falls below commitments. There is need to explore innovative domestic revenue collection mechanisms. Although inadequate funding for health is a fundamental problem, inefficient use of resources is of great concern. There is need to generate robust evidence focusing on issues of importance to ministry of finance. The current unsatisfactory state of health financing was mainly attributed to lack of clear vision; evidence based plans and costed strategies. DISCUSSION: Based on the analysis of discussion made, there are points of convergence and divergence in the discourse and positions of the two ministries. The current blockage points holding back budget allocations for health can be solved with a more evidence based approach and dialogue based on a clear vision and costed strategic plan articulated by the ministry of health. Improving health in Africa is a driver for long-term economic growth and development and this is the reason why the ministries of health and finance will need to find common ground on how to create policy coherence and how to articulate their respective objectives.

Prevalence of atopy, asthma and COPD in an urban and a rural area of an African country.

UNLABELLED: The objectives of this study were to determine the prevalence of asthma, atopy and COPD in Rwanda and to identify risk factors. The survey was conducted in Kigali, the Capital of Rwanda, and in Huye District, a rural area located in southern Rwanda. METHODS: A total of 2138 subjects were invited to participate in the study.1920 individuals (90%) answered to questionnaires on respiratory symptoms and performed spirometry, 1824 had acceptable spirograms and performed skin-prick test. In case of airflow obstruction (defined as pre-bronchodilator ratio FEV(1)/FVC < LLN) a post bronchodilator spirometry was performed. Reversibility was defined as an increase in FEV(1) of 200 ml and 12% above baseline FEV(1) after inhalation of 400 mcg of salbutamol. RESULTS: The mean age was 38.3 years; 48.1% of participants were males and 51.9% females. Airflow obstruction was found in 256 participants (14%); 163(8.9%) subjects were asthmatics and 82 (4.5%) had COPD. COPD was found in 9.6% of participants aged 45 years and above. 484 subjects had positive skin-prick tests (26.5%); house dust mite and grass pollen mix were the main allergens. Risk factors for asthma were allergy, female gender and living in Kigali. COPD was associated with cigarette smoking, age and male sex. CONCLUSION: this is the first study which shows the prevalence of atopy, asthma and COPD in Rwanda. Asthma and COPD were respectively diagnosed in 8.9% and 4.5% of participants. COPD was diagnosed in 9.6% of subjects aged ≥ 45 years.The prevalence of asthma was higher in urban compared to rural area.

Communities of practice: the missing link for knowledge management on implementation issues in low-income countries?

The implementation of policies remains a huge challenge in many low-income countries. Several factors play a role in this, but improper management of existing knowledge is no doubt a major issue. In this article, we argue that new platforms should be created that gather all stakeholders who hold pieces of relevant knowledge for successful policies. To build our case, we capitalize on our experience in our domain of practice, health care financing in sub-Saharan Africa. We recently adopted a community of practice strategy in the region. More in general, we consider these platforms as the way forward for knowledge management of implementation issues.

Is universal coverage via social health insurance financially feasible in Swaziland?

OBJECTIVE: The Government of Swaziland decided to explore the feasibility of social health insurance (SHI) in order to enhance universal access to health services. We assess the financial feasibility of a possible SHI scheme in Swaziland. The SHI scenario presented is one that mobilises resources additional to the maintained Ministry of Health and Social Welfare (MOHSW) budget. It is designed to increase prepayment, enhance overall health financing equity, finance quality improvements in health care, and eventually cover the entire population. METHODS: The financial feasibility assessment consists of calculating and projecting revenues and expenditures of the SHI scheme from 2008 to 2018. SimIns, a health insurance simulation software, was used. Quantitative data from government and other sources and qualitative data from discussions with health financing stakeholders were gathered. Policy assumptions were jointly developed with and agreed upon by a MOHSW team. RESULTS AND CONCLUSION: SHI would take up an increasing proportion of total health expenditure over the simulation period and become the dominant health financing mechanism. In principle, and on the basis of the assumed policy variables, universal coverage could be reached within 6 years through the implementation of an SHI scheme based on a mix of contributory and tax financing. Contribution rates for formal sector employees would amount to 7% of salaries and the Ministry of Health and Social Welfare budget would need to be maintained. Government health expenditure including social health insurance would increase from 6% in 2008 to 11% in 2018.

Mutual health insurance in Rwanda: evidence on access to care and financial risk protection.

OBJECTIVE: Rwanda has expanded mutual health insurance considerably in recent years, which has a great potential for making health services more accessible. In this paper, we examine the effect of mutual health insurance (MHI) on utilization of health services and financial risk protection. METHODS: We used data from a nationally representative survey from 2005-2006. We analysed this data through summary statistics as well as regression models. FINDINGS: Our statistical modelling shows that MHI coverage is associated with significantly increased utilization of health services. Indeed, individuals in households that had MHI coverage used health services twice as much when they were ill as those in households that had no insurance coverage. Additionally, MHI is also associated with a higher degree of financial risk protection and the incidence of catastrophic health expenditure was almost four times less than in households with no coverage. Nonetheless, the limitations of the MHI coverage also become apparent. CONCLUSION: These promising results indicate that MHI has had a strong positive impact on access to health care and can continue to improve health of Rwandans even more if its limitations are addressed further.

Output-based payment to boost staff productivity in public health centres: contracting in Kabutare district, Rwanda.

OBJECTIVE: In many low-income countries, public health systems do not meet the needs and demands of the population. We aimed to assess the extent to which output-based payment could boost staff productivity at health care facilities. METHODS: We assessed the performance of 15 health care centres in Kabutare, Rwanda, comparing productivity in 2001, when fixed annual bonuses were paid to staff, with that in 2003, when an output-based payment incentive scheme was implemented. FINDINGS: Changes to the structure of contracts were associated with improvements in health centre performance: specifically, output-based performance contracts induced sharp increases in the productivity of health staff. CONCLUSION: Institutional configurations of health care organizations deserve more attention. Those currently in place in the public sector may not the most suitable to meet current challenges in health care. More experiments are needed to confirm these early results from Rwanda and elsewhere, since risks associated with output-based incentive schemes should not be ignored.

Reviewing institutions of rural health centres: the Performance Initiative in Butare, Rwanda.

In many low-income countries, performance of pyramidal health systems with a public purpose is not meeting the expectations and needs of the populations they serve. A question that has not been studied and tested sufficiently is, 'What is the right package of institutional mechanisms required for organisations and individuals working in these health systems?' This paper presents the experience of the Performance Initiative, an innovative contractual approach that has reshaped the incentive structure in place in two rural districts of Rwanda. It describes the general background, the initial analysis, the institutional arrangement and the results after 3 years of operations. At this stage of the experience, it shows that 'output-based payment + greater autonomy' is a feasible and effective strategy for improving the performance of public health centres. As part of a more global package of strategies, contracting-in approaches could be an interesting option for governments, donors and non-governmental organisations in their effort to achieve some of the Millennium Development Goals.

Paying for health in two Rwandan provinces: financial flows and flaws.

The study intended to analyse the financial flows in two provinces within the Rwandan health system through the review of all available documentation and through interviews with key informants, to assess the scope for improved resource allocation. In Rwanda, there exists a large deficit of available financial resources in the health sector in general, and more specifically at health centre level. To improve this situation, it is considered to cover a large proportion of the entire population by mutual health insurance schemes. The schemes are able to pool certain risks, and they definitely improve financial access to health services. Nonetheless, they are inaccessible to the 'very poor', and--due to their limited financial base--they are unable to cover a complementary health care package. It is unlikely that they will mobilize substantial additional resources for health. External long-term commitments are required to cover this gap. A reassurance and readjustment system between the various insurance schemes should be established in order to increase financial protection provided. It might link up with insurance schemes in the formal employment sector. The combination of such a support for health insurance with performance-related incentives for health staff has the potential to increase both equity and quality of health services simultaneously and substantially.

[Profile of members and non members of mutual health insurance system in Rwanda: the case of the health district of Kabutare]. / Le profil des membres et des non membres des mutuelles de santé au Rwanda: le cas du district sanitaire de Kabutare.

The establishment of mutual health insurance systems is one of the priorities of the Rwandan government. Pilot studies have been conducted in three districts of the country. Nonetheless, after 4 years of implementation (1999-2003), the population coverage by these insurance systems remains relatively low. A cross-sectional study of 1042 households in the Kabutare health district allowed for a comparison of socio-economic and demographic variables, and the medical, surgical, gynaecological, and obstetrical history of health insurance scheme members and non-members. The results of the study demonstrate that the distribution of members and non-members is similar in terms of sex, marital status, professional status and medical history. However, larger households (more than five members) and those having a relatively higher income (more than USD 230 per annum) are more likely to be insured than other households. Members of the mutual health insurance use more the health services than non-members, spend less on health care and increasingly maintain membership. The study emphasizes the relevance to further promote mutual health insurance, but also points to the need for mechanisms to ensure financial access for the poor rural population.

[The prepayment scheme in Rwanda (II): membership and use of services by beneficiaries]. / Le système de prépaiement au Rwanda (II): adhésion et utilisation des services par les bénéficiaires.

In Rwanda, the Ministry of Health is rebuilding the health sector destroyed during the genocide while trying to guarantee the financial accessibility of the population to the services through the setting up of a prepayment scheme. Membership remains low in the three pilot districts where the prepayment scheme was introduced four years before (15,6%). In two of these districts, the curative consultation and maternity utilisation has increased appreciably. The members of the prepayment scheme make greater use of the services than the rest of the population. There is a significantly higher prepayment scheme membership among households with a relatively high income and those with a large family (more than 5 family members). Overall, non-members of the prepayment scheme spend more on health services than members do. There are indications that developing the prepayment scheme would be very useful for the people in Rwanda if specific strategies geared to the poor were set up.

[The prepayment scheme in Rwanda (I): analysis of a pilot experiment]. / Le système de prépaiement au Rwanda (I): analyse d'une expérience pilote.

Rwanda has made the setting up of a prepayment scheme a priority in its health sector reform in order to make health services more financially accessible to the population. A pilot study was carried out in three districts. The yearly family subscription charge was fixed at 7.9 US dollars, which covers care delivered at Health Centre level as well as some services at the hospital. The beneficiaries and providers mention difficulties in order to mobilise the subscription charges all at a time, the insufficiency of the offer of services at the hospital and the absence of involvement of the political authorities in the process. The Ministry of Health did initiate the experiment but the choice of the privileged pilot districts prevents results from being extrapolated to the country taken as a whole with a view to a possible extension at a later stage. Given the relatively short time in which it has taken place, the population could neither understand the contingency and solidarity issues implied nor have the opportunity to feel personally involved in the system. As a conclusion, the study advocates the continuation of the experiment with a reinforcement of the coordination which should take the weak points identified into account.