Change in economic burden of diarrhoea in children under-five in Bangladesh: 2007 vs. 2018.

Background: In Bangladesh, diarrhoea in children under-five is a major public health problem with cost implications. Although under-five diarrhoea mortality and morbidity have declined from 2007 to 2018, change in the economic burden is unknown. This study determined the change in the societal economic burden of under-five diarrhoea in Bangladesh comparing 2007 to 2018. Methods: A prevalence-based, retrospective cost analysis was conducted from a societal perspective, including costs to households, providers, and economic loss from premature deaths. Data were obtained from the previous cost of illness studies, government reports, and international databases. Direct costs for treatment were estimated by the bottom-up costing approach. Indirect costs on the loss of productivity of caretakers and loss from premature deaths were calculated by the human capital method. Total costs were presented in both local currency (Bangladeshi Taka (BDT)) and US dollars (US$)) in 2018 price. Sensitivity analyses were conducted to assess the robustness of the input parameters. Results: A 36.4% reduction was found on the economic burden of under-five diarrhoea when comparing 2007 and 2018; US$1 209 million (95% CI = 1066 million-1299 million) for 2007 and US$769 million (95% CI = 484 million-873 million) for 2018. Economic loss from premature deaths imposed the highest costs (2007 = 66%, 2018 = 66% of all) followed by indirect costs on the loss of productivity of caretakers (2007 = 21%, 2018 = 26%) and direct medical costs (2007 = 13%, 2018 = 8%). Conclusions: Societal costs from diarrhoeal diseases were reduced from 2007 to 2018 in Bangladesh. However, the economic burden was equivalent to 0.29% of country's gross domestic product in 2018 and remains a challenge. The major contributor to the costs was premature mortality from diarrhoeal diseases. Premature deaths are still prevalent though they to a large extent are avoidable. To further limit the economic burden, under-five diarrhoea mortality and morbidity reduction should be accelerated.

Cost analysis of negative-pressure wound therapy versus standard treatment of acute conflict-related extremity wounds within a randomized controlled trial.

BACKGROUND: Clinical outcomes after negative-pressure wound therapy (NPWT) and standard treatment of conflict-related extremity wounds are similar. In resource-limited settings, cost affects the choice of treatment. We aimed to estimate treatment-related costs of NPWT in comparison with standard treatment for conflict-related extremity wounds. METHODS: We derived outcome data from a randomized, controlled superiority trial that enrolled adult (≥ 18 years) patients with acute (≤ 72 h) conflict-related extremity wounds at two civilian hospitals in Jordan and Iraq. Primary endpoint was mean treatment-related healthcare costs (adjusted to 2019 US dollars). RESULTS: Patients were enrolled from June 9, 2015, to October 24, 2018. A total of 165 patients (155 men [93.9%]; 10 women [6.1%]; and median [IQR] age, 28 [21-34] years) were included in the analysis. The cost per patient treated with NPWT was $142 above that of standard treatment. Overall, results were robust in a sensitivity analysis. CONCLUSIONS: With similar clinical outcomes compared to standard care, our results do not support the use of NPWT in routine treatment of conflict-related extremity wounds at civilian hospitals in resource scarce settings. Trial registration NCT02444598.

Results-Based Financing for Health: A Case Study of Knowledge and Perceptions Among Stakeholders in a Donor-Funded Program in Zambia.

In 2015, the Zambian government and the Swedish International Development Cooperation Agency (Sida) signed an agreement in which Sida committed to funding a program for Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH). The program includes a results-based financing (RBF) model that aims to reward Zambian districts for improved district-wide results on relevant indicators with additional funding. We aimed to describe stakeholders' knowledge of the RBF model and perceptions of the incentive structure during the first 18 months of the program's implementation. This study illuminates the possible pitfalls of implementing an RBF scheme without giving attention to all necessary steps of the process. A qualitative case study was used and included a review of documents, in-depth interviews, and observations. From February-April 2017, we conducted 37 in-depth interviews, representing the views of 12 development partner agencies, government departments, and health facility staff throughout Zambia. We used a qualitative framework analysis. Findings show that the Zambian government and Sida had different perceptions on what levels of the health system RBF will incentivize and that most districts and hospital administrators interviewed were unaware of the indicators that the RBF was part of the RMNCAH program at all. The lack of knowledge about the RBF scheme among respondents suggests the possibility that the model did not ultimately have the necessary preconditions to create an effective incentive structure. These results demonstrate the need for improved communication between stakeholders and the importance of sufficiently planning an RBF model before implementation.

Early detection of type 2 diabetes in socioeconomically disadvantaged areas in Stockholm - comparing reach of community and facility-based screening.

BACKGROUND: Type 2 diabetes and its high-risk stage, prediabetes, are often undiagnosed. Early detection of these conditions is of importance to avoid organ complications due to the metabolic disturbances associated with diabetes. Diabetes screening can detect persons unaware of diabetes risk and the elevated glucose levels can potentially be reversed through lifestyle modification and medication. There are mainly two approaches to diabetes screening: opportunistic facility-based screening at health facilities and community screening. OBJECTIVE: To determine the difference in population reach and participant characteristics between community- and facility-based screening for detection of type 2 diabetes and persons at high risk of developing diabetes. METHODS: Finnish diabetes risk score (FINDRISC) is a risk assessment tool used by two diabetes projects to conduct community- and facility-based screenings in disadvantaged suburbs of Stockholm. In this study, descriptive and limited inferential statistics were carried out analyzing data from 2,564 FINDRISC forms from four study areas. Community- and facility-based screening was compared in terms of participant characteristics and with population data from the respective areas to determine their reach. RESULTS: Our study found that persons born in Africa and Asia were reached through community screening to a higher extent than with facility-based screening, while persons born in Sweden and other European countries were reached more often by facility-based screening. Also, younger persons were reached more frequently through community screening compared with facility-based screening. Both types of screening reached more women than men. CONCLUSION: Community-based screening and facility-based screening were complementary methods in reaching different population groups at high risk of developing type 2 diabetes. Community screening in particular reached more hard-to-reach groups with unfavorable risk profiles, making it a critical strategy for T2D prevention. More men should be recruited to intervention studies and screening initiatives to achieve a gender balance.

Indicators to evaluate organisational knowledge brokers: a scoping review.

BACKGROUND: Knowledge translation (KT) is currently endorsed by global health policy actors as a means to improve outcomes by institutionalising evidence-informed policy-making. Organisational knowledge brokers, comprised of researchers, policy-makers and other stakeholders, are increasingly being used to undertake and promote KT at all levels of health policy-making, though few resources exist to guide the evaluation of these efforts. Using a scoping review methodology, we identified, synthesised and assessed indicators that have been used to evaluate KT infrastructure and capacity-building activities in a health policy context in order to inform the evaluation of organisational knowledge brokers. METHODS: A scoping review methodology was used. This included the search of Medline, Global Health and the WHO Library databases for studies regarding the evaluation of KT infrastructure and capacity-building activities between health research and policy, published in English from 2005 to 2016. Data on study characteristics, outputs and outcomes measured, related indicators, mode of verification, duration and/or frequency of collection, indicator methods, KT model, and targeted capacity level were extracted and charted for analysis. RESULTS: A total of 1073 unique articles were obtained and 176 articles were qualified to be screened in full-text; 32 articles were included in the analysis. Of a total 213 indicators extracted, we identified 174 (174/213; 81.7%) indicators to evaluate the KT infrastructure and capacity-building that have been developed using methods beyond expert opinion. Four validated instruments were identified. The 174 indicators are presented in 8 domains based on an adaptation of the domains of the Lavis et al. framework of linking research to action - general climate, production of research, push efforts, pull efforts, exchange efforts, integrated efforts, evaluation and capacity-building. CONCLUSION: This review presents a total of 174 method-based indicators to evaluate KT infrastructure and capacity-building. The presented indicators can be used or adapted globally by organisational knowledge brokers and other stakeholders in their monitoring and evaluation work.

Universal Health Coverage in Marginalized Populations: A Qualitative Evaluation of a Health Reform Implementation in Rural Ecuador.

In 2008, Ecuador underwent a major health reform with the aim of universal coverage. Little is known about the implementation of the reform and its perceived effects in rural parts of the country. The aim of this study was to explore the perceived effects of the 2008 health reform implementation, on rural primary health care services and financial access of the rural poor. A qualitative study using focus group discussions was conducted in a rural region in Ecuador, involving health staff, local health committee members, village leaders, and community health workers. Qualitative content analysis focusing on the manifest content was applied. Three categories emerged from the texts: (1) the prereform situation, which was described as difficult in terms of financial access and quality of care; (2) the reform process, which was perceived as top-down and lacking in communication by the involved actors; lack of interest among the population was reported; (3) the effects of the reform, which were mainly perceived as positive. However, testimonies about understaffing, drug shortages, and access problems for those living furthest away from the health units show that the reform has not fully achieved its intended effects. New problems are a challenging health information system and people without genuine care needs overusing the health services. The results indicate that the Ecuadorean reform has improved rural primary health care services. Still, the reform faces challenges that need continued attention to secure its current achievements and advance the health system further.

Universal Health Coverage in Rural Ecuador: A Cross-sectional Study of Perceived Emergencies.

INTRODUCTION: In many low- and middle-income countries emergency care is provided anywhere in the health system; however, no studies to date have looked at which providers are chosen by patients with perceived emergencies. Ecuador has universal health coverage that includes emergency care. However, earlier research indicates that patients with emergencies tend to seek private care. Our primary research questions were these: What is the scope of perceived emergencies?; What is their nature?; and What is the related healthcare-seeking behavior? Secondary objectives were to study determinants of healthcare-seeking behavior, compare health expenditure with expenditure from the past ordinary illness, and measure the prevalence of catastrophic health expenditure related to perceived emergencies. METHODS: We conducted a cross-sectional survey of 210 households in a rural region of northwestern Ecuador. The households were sampled with two-stage cluster sampling and represent an estimated 20% of the households in the region. We used two structured, pretested questionnaires. The first questionnaire collected demographic and economic household data, expenditure data on the past ordinary illness, and presented our definition of perceived emergency. The second recorded the number of emergency events, symptoms, further case description, healthcare-seeking behavior, and health expenditure, which was defined as being catastrophic when it exceeded 40% of a household's ability to pay. RESULTS: The response rate was 85% with a total of 74 reported emergency events during the past year (90/1,000 inhabitants). We further analyzed the most recent event in each household (n=54). Private, for-profit providers, including traditional healers, were chosen by 57.4% (95% confidence interval [CI] [44-71%]). Public providers treated one third of the cases. The mean health expenditure per event was $305.30 United States dollars (USD), compared to $135.80 USD for the past ordinary illnesses. Catastrophic health expenditure was found in 24.4% of households. CONCLUSION: Our findings suggest that the provision of free health services may not be sufficient to reach universal health coverage for patients with perceived emergencies. Changes in the organization of public emergency departments and improved financial protection for emergency patients may improve the situation.

A case management intervention targeted to reduce healthcare consumption for frequent Emergency Department visitors: results from an adaptive randomized trial.

BACKGROUND: A small group of frequent visitors to Emergency Departments accounts for a disproportionally large fraction of healthcare consumption including unplanned hospitalizations and overall healthcare costs. In response, several case and disease management programs aimed at reducing healthcare consumption in this group have been tested; however, results vary widely. OBJECTIVES: To investigate whether a telephone-based, nurse-led case management intervention can reduce healthcare consumption for frequent Emergency Department visitors in a large-scale setup. METHODS: A total of 12 181 frequent Emergency Department users in three counties in Sweden were randomized using Zelen's design or a traditional randomized design to receive either a nurse-led case management intervention or no intervention, and were followed for healthcare consumption for up to 2 years. RESULTS: The traditional design showed an overall 12% (95% confidence interval 4-19%) decreased rate of hospitalization, which was mostly driven by effects in the last year. Similar results were achieved in the Zelen studies, with a significant reduction in hospitalization in the last year, but mixed results in the early development of the project. CONCLUSION: Our study provides evidence that a carefully designed telephone-based intervention with accurate and systematic patient selection and appropriate staff training in a centralized setup can lead to significant decreases in healthcare consumption and costs. Further, our results also show that the effects are sensitive to the delivery model chosen.

Pharmacy-based dispensing of antimicrobial agents without prescription in India: appropriateness and cost burden in the private sector.

BACKGROUND: Inappropriate antibiotic use for treatment of common self-limiting infections is a major problem worldwide. We conducted this study to determine prevalence of non-prescription sale of antimicrobial drugs by pharmacies in Bangalore, India, and to assess their associated avoidable cost within the Indian private healthcare sector. METHODS: Between 2013 and 2014, two researchers visited 261 pharmacies with simulated clinical scenarios; upper respiratory tract infection in an adult and acute gastroenteritis in a child. Using a pre-defined algorithm, the researchers recorded questions asked by the pharmacist, details of medicines dispensed, and instructions regarding drug allergies, dose and side effects. RESULTS: Antimicrobial drugs were obtained without prescription from 174 of 261 (66.7 %) pharmacies visited. Instructions regarding dose of these drugs were given by only 58.0 % pharmacies. Only 18.4 % (16/87) of non-antimicrobial-dispensing pharmacies cited the need for a prescription by a medical practitioner. None gave advice on potential side effects or possible drug allergies. In the upper respiratory infection simulation, 82 (71.3 %) of the 115 pharmacies approached dispensed antimicrobials without a prescription. The most common antimicrobial drug prescribed was amoxicillin (51.2 %), followed by azithromycin and ciprofloxacin (12.2 % each). Among 146 pharmacies where acute gastroenteritis was simulated, 92 (63.0 %) dispensed antimicrobials. Common ones were fluoroquinolones (66.3 %), particularly norfloxacin in combination with metronidazole. Standard treatment for diarrhea such as oral rehydration solution and zinc was prescribed by only 18 of 146 (12.3 %) pharmacies. Assuming the average cost of a 5-day course of common antimicrobials in India is $1.93, with 2.5 and 2.1 annual episodes of adult upper respiratory and childhood gastrointestinal infections respectively, and with 30-45 % of the population of 1.3 billion visiting pharmacies, the estimated cost of unnecessary antimicrobial drugs dispensed by pharmacies in India would range from $1.1 to 1.7 billion. CONCLUSIONS: The study shows that dispensing of antimicrobial drugs without prescription by pharmacies in the private sector in India within an urban setting was unacceptably high, thus placing a high burden on healthcare expenditure. There is an urgent need to institute measures to curb unnecessary antimicrobial usage in India, address market incentives and involve pharmacists as partners for creating awareness among communities.

Cost of surgery in a low-income setting in eastern Uganda.

BACKGROUND: Operative interventions have traditionally been seen as expensive; therefore, surgery has been given low priority in global health care planning in low-income countries. A growing body of evidence indicates that surgery can also be highly cost effective in low-income settings, but our current knowledge of the actual cost of surgery in such settings is limited. This study was carried out to obtain data on the costs of commonly performed operative procedures in a rural/semiurban setting in eastern Uganda. METHODS: A prospective, facility-based study carried out at a general district hospital (public) and a mission hospital (private, not-for-profit) in the Iganga and Mayuge districts in eastern Uganda. Items included in the cost calculations were staff time, materials and medicines, overhead costs, and capital costs. RESULTS: The cost of surgery was higher at the mission hospital, with higher expenditure and lower productivity than the public hospital. The most commonly performed major procedures were caesarean section, uterine evacuation, and herniorrhaphy for groin hernia. The costs for these interventions varied between $68.4 and $74.4, $25.0 and $32.6, and $58.6 and $66.0, respectively. The most commonly performed minor procedures were circumcision, suture of cuts and lacerations, and incision and drainage of abscess. The costs for these interventions varied between $16.2 and $24.6, $15.8 and $24.3, and $10.1 and $18.6, respectively. CONCLUSION: The cost of surgery in the study setting compares favorably with other prioritized health care interventions, such as treatment for tuberculosis, human immunodeficiency virus/AIDS, and childhood immunization. Surgery in low-income settings can be made more cost effective, leading to increased quantity and improved quality of surgical services.

Differences in essential newborn care at birth between private and public health facilities in eastern Uganda.

BACKGROUND: In Uganda and elsewhere, the private sector provides an increasing and significant proportion of maternal and child health services. However, little is known whether private care results in better quality services and improved outcomes compared to the public sector, especially regarding care at the time of birth. OBJECTIVE: To describe the characteristics of care-seekers and assess newborn care practices and services received at public and private facilities in rural eastern Uganda. DESIGN: Within a community-based maternal and newborn care intervention with health systems strengthening, we collected data from mothers with infants at baseline and endline using a structured questionnaire. Descriptive, bivariate, and multivariate data analysis comparing nine newborn care practices and three composite newborn care indicators among private and public health facilities was conducted. RESULTS: The proportion of women giving birth at private facilities decreased from 25% at baseline to 17% at endline, whereas overall facility births increased. Private health facilities did not perform significantly better than public health facilities in terms of coverage of any essential newborn care interventions, and babies were more likely to receive thermal care practices in public facilities compared to private (68% compared to 60%, p=0.007). Babies born at public health facilities received an average of 7.0 essential newborn care interventions compared to 6.2 at private facilities (p<0.001). Women delivering in private facilities were more likely to have higher parity, lower socio-economic status, less education, to seek antenatal care later in pregnancy, and to have a normal delivery compared to women delivering in public facilities. CONCLUSIONS: In this setting, private health facilities serve a vulnerable population and provide access to service for those who might not otherwise have it. However, provision of essential newborn care practices was slightly lower in private compared to public facilities, calling for quality improvement in both private and public sector facilities, and a greater emphasis on tracking access to and quality of care in private sector facilities.

Predicting performance in contracting of basic health care to NGOs: experience from large-scale contracting in Uttar Pradesh, India.

Escalating costs and increasing pressure to improve health services have driven a trend toward contracting with the private sector to provide traditionally state-run services. Such contracting is seen as an opportunity to combine theorized advantages of contracting with the efficiency of the private sector. There is still a limited understanding of the preconditions for successful use of contracting and the resources needed for their appropriate use and sustainability. This study assesses the large-scale contracting of 294 non-governmental organizations (NGOs) for delivery of basic health services in Uttar Pradesh, a state with almost 170 million in India. Due to high rates of discontinuation or non-renewal of contracts based on poor performance in the project, a better method for selecting partners was requested. Data on characteristics of the NGOs (intake data) and performance/outcome monitoring indicators were combined to identify correlations. The results showed that NGOs selected were generally small but well-established, had implemented at least two large projects, and had more non-health experience than health experience. Bivariate regressions of outcome score on each input variable showed that training experience, proposal quality and having 'health' contained in the objectives of the organization were statistically significant predictors of good performance. Factors relating to financial capacity, staff qualification, previous experience with health or non-health projects, and age of establishment were not. A combined training plus proposal score was highly predictive of outcome score (ß = 1.37, P < 0.001). The combined score was found to be a much better predictor of outcome scores than a total score used to select NGOs (ß = 0.073, P = 0.539). The study provides valuable information from large-scale contracting. Conclusions on criteria for selecting NGOs for providing basic health care could guide other governments choosing to contract for such services.

The Paris Declaration in practice: challenges of health sector aid coordination at the district level in Zambia.

BACKGROUND: The increasing resources available for and number of partners providing health sector aid have stimulated innovations, notably, the Paris Declaration on Aid Effectiveness, which aim to improve aid coordination. In this, one of the first studies to analyse implementation of aid coordination below national level, the aim was to investigate the effect of the Paris Declaration on coordination of health sector aid at the district level in Zambia. METHODS: The study was carried out in three districts of Zambia. Data were collected via interviews with health centre staff, district managers and officials from the Ministry of Health, and from district action plans, financial reports and accounts, and health centre ledger cards. Four indicators of coordination related to external-partner activity, common arrangements used by external partners and predictability of funding were analysed and assessed in relation to the 2010 targets set by the Paris Declaration. FINDINGS: While the activity of external partners at the district level has increased, funding and activities provided by these partners are often not included in local plans. HIV/AIDS support show better integration in planning and implementation at the district level than other support. Regarding common arrangements used for fund disbursement, the share of resources provided as programme-based support is not increasing. The predictability of funds coming from outside the government financing mechanism is low. CONCLUSION: Greater efforts to integrate partners in district level planning and implementation are needed. External partners must improve the predictability of their support and be more proactive in informing the districts about their intended contributions. With the deadline for achieving the targets set by the Paris Declaration fast approaching, it is time for the signatories to accelerate its implementation.

Willingness and ability to pay for artemisinin-based combination therapy in rural Tanzania.

BACKGROUND: The aim of this study was to analyse willingness to pay (WTP) and ability to pay (ATP) for ACT for children below five years of age in a rural setting in Tanzania before the introduction of artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated malaria. Socio-economic factors associated with WTP and expectations on anti-malaria drugs, including ACT, were also explored. METHODS: Structured interviews and focus group discussions were held with mothers, household heads, health-care workers and village leaders in Ishozi, Gera and Ishunju wards in north-west Tanzania in 2004. Contingent valuation method (CVM) was used with "take-it-or-leave-it" as the eliciting method, expressed as WTP for a full course of ACT for a child and households' opportunity cost of ACT was used to assess ATP. The study included descriptive analyses with multivariate adjustment for potential confounding factors. RESULTS: Among 265 mothers and household heads, 244 (92%, CI = 88%-95%) were willing to pay Tanzanian Shillings (TSh) 500 (US$ 0.46) for a child's dose of ACT, but only 55% (49%-61%) were willing to pay more than TSh 500. Mothers were more often willing to pay than male household heads (adjusted odds ratio = 2.1, CI = 1.2-3.6). Socio-economic status had no significant effect on WTP. The median annual non-subsidized ACT cost for clinical malaria episodes in an average household was calculated as US$ 6.0, which would represent 0.9% of the average total consumption expenditures as estimated from official data in 2001. The cost of non-subsidized ACT represented 7.0% of reported total annual expenditure on food and 33.0% of total annual expenditure on health care."Rapid effect," "no adverse effect" and "inexpensive" were the most desired features of an anti-malarial drug. CONCLUSION: WTP for ACT in this study was less than its real cost and a subsidy is, therefore, needed to enable its equitable affordability. The decision taken in Tanzania to subsidize Coartem fully at governmental health care facilities and at a consumer price of TSh 300-500 (US$ 0.28-0.46) at special designated shops through the programme of Accredited Drug Dispensing Outlets (ADDOs) appears to be well founded.

Exploring SWAp's contribution to the efficient allocation and use of resources in the health sector in Zambia.

Zambia introduced a sector-wide approach (SWAp) in the health sector in 1993. The goal was to improve efficiency in the use of domestic funds and externally sourced development assistance by integrating these into a joint sectoral framework. Over a decade into its existence, however, the SWAp remains largely unevaluated. This study explores whether the envisaged improvements have been achieved by studying developments in administrative, technical and allocative efficiency in the Zambian health sector from 1990-2006. A case study was conducted using interviews and analysis of secondary data. Respondents represented a cross-section of stakeholders in the Zambian health sector. Secondary data from 1990-2006 were collected for six indicators related to administrative, technical and allocative efficiency. The results showed small improvements in administrative efficiency. Transaction costs still appeared to be high despite the introduction of the SWAp. Indicators for technical efficiency showed a drop in hospital bed utilization rates and government share of funding for drugs. As for allocative efficiency, budget execution did not improve with the SWAp, although there were large variations between both donors and year. Funding levels had apparently improved at district level but declined for hospitals. Finally, the SWAp had not succeeded in bringing all external assistance together under a common framework. Despite strong commitment to implement the SWAp in Zambia, the envisaged efficiency improvements do not seem to have been attained. Possible explanations could be that the SWAp has not been fully developed or that not all parties have completely embraced it. SWAp is not ruled out as a coordination model, but the current setup in Zambia has not proved to be fully effective.