Fiscal space for the immunisation program in Zambia- an efficiency analysis approach.

OBJECTIVE: The immunisation programme in Zambia remains one of the most effective public health programmes. Its financial sustainability is, however, uncertain. Using administrative data on immunisation coverage rate, vaccine utilisation, the number of health facilities and human resources, expenditure on health promotion, and the provision of outreach services from 24 districts, we used Data Envelopment Analysis to determine the level of technical efficiency in the provision of immunisation services. Based on our calculated levels of technical efficiency, we determined the available fiscal space for immunisation. RESULTS: Out of the 24 districts in our sample, 9 (38%) were technically inefficient in the provision of immunisation services. The average efficiency score, however, was quite high, at 0.92 (CRS technology) and 0.95 (VRS technology). Based on the calculated level of technical efficiency, we estimated that an improvement in technical efficiency can save enough vaccine doses to supply between 5 and 14 additional districts. The challenge, however, lies in identifying and correcting for the sources of technical inefficiency.

Effects of performance based financing on facility autonomy and accountability: Evidence from Zambia.

Several low and lower- middle income countries have been using Performance-Based Financing (PBF) to motivate health workers to increase the quantity and quality of health services. Studies have demonstrated that PBF can contribute to improved health service delivery and health outcomes, but there is limited evidence on the mechanisms through which PBF can necessitate changes in the health system. Using difference-in-difference and synthetic control analytical approaches, we investigated the effect of PBF on autonomy and accountability at service delivery level using data from a 3-arm cluster randomised trial in Zambia. The arms consisted of PBF where financing is linked to outputs in terms of quality and quantity (intervention 1), input financing where funding is fully provided to finance all required inputs regardless of performance (intervention 2), and the current standard of care where there is input financing but with possible challenges in funding (pure control). The results show an increase in autonomy at PBF sites compared to sites in the pure control arm and an increase in accountability at PBF sites compared to sites in both the input-financing and pure control arms. On the other hand, there were no effects on autonomy and accountability in the input-financing sites compared to the pure control sites. The study concludes that PBF can improve financial and managerial autonomy and accountability, which are important for improving health service delivery. However, within the PBF districts, the magnitude of change was different, implying that management and leadership styles matter. Future research could examine whether personal attributes, managerial capacities of the facility managers, and the operating environment have an effect on autonomy and accountability.

Looking at the bigger picture: effect of performance-based contracting of district health services on equity of access to maternal health services in Zambia.

Zambia has been using output-based approaches for over two decades to finance whole or part of the public health system. Between 1996 and 2006, performance-based contracting (PBC) was implemented countrywide with the Central Board of Health (CBoH) as the provider of health services. This study reviews the association between PBC and equity of access to maternal health services in Zambia between 1996 and 2006. A comprehensive document review was undertaken to evaluate the implementation process, followed by a trend analysis of health expenditure at district level, and a segmented regression analysis of data on antenatal care (ANC) and deliveries at health facilities that was obtained from five demographic and health survey datasets (1992, 1996, 2002, 2007 and 2014). The results show that PBC was anchored by high-level political support, an overarching policy and legal framework, and collective planning and implementation with all key stakeholders. Decentralization of health service provision was also an enabling factor. ANC coverage increased in both the lower and upper wealth quintiles during the PBC era, followed by a declining trend after the PBC era in both quintiles. Further, the percentage of women delivering at health facilities increased during the PBC era, particularly in rural areas and among the poor. The positive trend continued after the PBC era with similar patterns in both lower and upper wealth quintiles. Despite these gains, per capita health expenditure at district level declined during the PBC era, with the situation worsening after the PBC era. The study concludes that a nationwide PBC approach can contribute to improved equity of access to maternal health services and that PBC is a cost-efficient and sustainable policy reform. The study calls for policymakers to comprehensively evaluate the impact of health system reforms before terminating them.

Mathematical modelling for health systems research: a systematic review of system dynamics and agent-based models.

BACKGROUND: Mathematical modelling has been a vital research tool for exploring complex systems, most recently to aid understanding of health system functioning and optimisation. System dynamics models (SDM) and agent-based models (ABM) are two popular complementary methods, used to simulate macro- and micro-level health system behaviour. This systematic review aims to collate, compare and summarise the application of both methods in this field and to identify common healthcare settings and problems that have been modelled using SDM and ABM. METHODS: We searched MEDLINE, EMBASE, Cochrane Library, MathSciNet, ACM Digital Library, HMIC, Econlit and Global Health databases to identify literature for this review. We described papers meeting the inclusion criteria using descriptive statistics and narrative synthesis, and made comparisons between the identified SDM and ABM literature. RESULTS: We identified 28 papers using SDM methods and 11 papers using ABM methods, one of which used hybrid SDM-ABM to simulate health system behaviour. The majority of SDM, ABM and hybrid modelling papers simulated health systems based in high income countries. Emergency and acute care, and elderly care and long-term care services were the most frequently simulated health system settings, modelling the impact of health policies and interventions such as those targeting stretched and under resourced healthcare services, patient length of stay in healthcare facilities and undesirable patient outcomes. CONCLUSIONS: Future work should now turn to modelling health systems in low- and middle-income countries to aid our understanding of health system functioning in these settings and allow stakeholders and researchers to assess the impact of policies or interventions before implementation. Hybrid modelling of health systems is still relatively novel but with increasing software developments and a growing demand to account for both complex system feedback and heterogeneous behaviour exhibited by those who access or deliver healthcare, we expect a boost in their use to model health systems.

Estimating the economic and social consequences for patients diagnosed with human African trypanosomiasis in Muchinga, Lusaka and Eastern Provinces of Zambia (2004-2014).

BACKGROUND: Acute human African trypanosomiasis (rHAT) caused by Trypanosoma brucei rhodesiense is associated with high mortality and is fatal if left untreated. Only a few studies have examined the psychological, social and economic impacts of rHAT. In this study, mixed qualitative and quantitative research methods were used to evaluate the socio-economic impacts of rHAT in Mambwe, Rufunsa, Mpika and Chama Districts of Zambia. METHODS: Individuals diagnosed with rHAT from 2004 to 2014 were traced using hospital records and discussions with communities. Either they, or their families, were interviewed using a structured questionnaire and focus group discussions were conducted with affected communities. The burden of the disease was investigated using disability adjusted life years (DALYs), with and without discounting and age-weighting. The impact of long-term disabilities on the rHAT burden was also investigated. RESULTS: Sixty four cases were identified in the study. The majority were identified in second stage, and the mortality rate was high (12.5%). The total number of DALYs was 285 without discounting or age-weighting. When long-term disabilities were included this estimate increased by 50% to 462. The proportion of years lived with disability (YLD) increased from 6.4% to 37% of the undiscounted and un-age-weighted DALY total. When a more active surveillance method was applied in 2013-2014 the cases identified increased dramatically, suggesting a high level of under-reporting. Similarly, the proportion of females increased substantially, indicating that passive surveillance may be especially failing this group. An average of 4.9 months of productive time was lost per patient as a consequence of infection. The health consequences included pain, amnesia and physical disability. The social consequences included stigma, dropping out of education, loss of friends and self-esteem. Results obtained from focus group discussions revealed misconceptions among community members which could be attributed to lack of knowledge about rHAT. CONCLUSIONS: The social and economic impact of rHAT on rural households and communities is substantial. Improved surveillance and strengthening of local medical services are needed for early and accurate diagnosis. Disease prevention should be prioritised in communities at risk of rHAT, and interventions put in place to prevent zoonotic disease spill over from domestic animals and wildlife. Supportive measures to mitigate the long-term effects of disability due to rHAT are needed.

Assessing care-givers' satisfaction with child immunisation services in Zambia: Evidence from a national survey.

AIM: The main aim of this study was to assess care-giver satisfaction with vaccination services in public health facilities in Zambia, and examine its determinants. METHODS: This study used data from a recent population-based household survey, conducted from May to August 2015. Respondent satisfaction with vaccination services received during the last visit was measured on a five point Likert scale ranging from 1 to 5. We used an ordered logistic regression model to analyse the significance of perceived quality of vaccination services, immunisation delivery mode and a range of individual characteristics in predicting care-giver satisfaction. RESULTS: Findings show that one in five care givers were unsatisfied with the vaccination services that they had received, with rural populations showing a significantly higher level of satisfaction. Poor quality of care, defined by long waiting times, poor quality of communication between health staff and care givers, long distance to vaccination sites, mode of delivery, and personal characteristics were among major factors driving care-giver satisfaction ratings. We also find that receiving a vaccination at outreach mode of delivery was associated with higher odds of greater satisfaction compared to on-facility vaccination services. The odds of satisfaction were lower for respondents living further away from a health facility, which emphasizes the importance of access in seeking vaccination services. CONCLUSION: These findings suggest that major improvements in quality of vaccination and service organisation will be needed to increase client satisfaction and service utilisation.

An assessment of the effect of user fee policy reform on facility-based deliveries in rural Zambia.

BACKGROUND: Improving maternal health outcomes by reducing barriers to accessing maternal health services is a key goal for most developing countries. This paper analyses the effect of user fee removal, which was announced for rural areas of Zambia in April 2006, on the use of public health facilities for childbirth. METHODS: Data from the 2007 Zambia Demographic and Health Survey, including birth histories for the five years preceding the survey, is linked to administrative data and geo-referenced health facility census data. We exploit a difference-in-differences design, due to a differential change in user fees at the district level; fees were removed in 54 rural districts, but not in the 18 remaining urban districts. We use multilevel modelling to estimate the effect of this policy change, based on 4018 births from May 2002 to September 2007, covering a period before and after the policy announcement in April 2006. RESULTS: The difference-in-difference estimates point to statistically insignificant changes in the proportion of women giving birth at home and in public facilities, but significant changes are found for deliveries in private (faith-based) facilities. Thus, the abolition of delivery fees is found to have some effect on where Zambian mothers choose to have their children born. CONCLUSION: The removal of user fees has not overcome barriers to the utilisation of delivery services at public facilities. User fee removal may also yield unintended consequences deterring the utilisation of delivery services. Therefore, abolishing user fees, alone, may not be sufficient to affect changes in utilisation; instead, other efforts, such as improving service quality, may have a greater impact.