The impact and cost-effectiveness of user fee exemption by contracting out essential health package services in Malawi.

OBJECTIVES: To examine the impact and cost-effectiveness of user fee exemption by contracting out essential health package services to Christian Health Association of Malawi (CHAM) facilities through service-level agreements (SLAs) to inform policy-making in Malawi. METHODS: The analysis was conducted from the government perspective. Financial and service utilisation data were collected for January 2015 through December 2016. The impact of SLAs on utilisation of maternal and child health (MCH) services was examined using propensity score matching and random-effects models. Subsequently, the improved services were converted to quality-adjusted life years (QALYs) gained, using the Lives Saved Tool (LiST), and incremental cost-effectiveness ratios (ICERs) were generated. FINDINGS: Over the 2 years, a total of $1.5 million was disbursed to CHAM facilities through SLAs, equivalent to $1.24 per capita. SLAs were associated with a 13.8%, 13.1%, 19.2% and 9.6% increase in coverage of antenatal visits, postnatal visits, delivery by skilled birth attendants and BCG vaccinations, respectively. This was translated into 434 lives saved (95% CI 355 to 512) or 11 161 QALYs gained (95% CI 9125 to 13 174). The ICER of SLAs was estimated at $134.7/QALYs gained (95% CI $114.1 to $164.7). CONCLUSIONS: The cost per QALY gained for SLAs was estimated at $134.7, representing 0.37 of Malawi's per capita gross domestic product ($363). Thus, MCH services provided with Malawi's SLAs proved cost-effective. Future refinements of SLAs could introduce pay for performance, revising the price list, streamlining the reporting system and strengthening CHAM facilities' financial and monitoring management capacity.

Government stewardship of the for-profit private health sector in Afghanistan.

BACKGROUND: Since 2003, Afghanistan's largely unregulated for-profit private health sector has grown at a rapid pace. In 2008, the Ministry of Public Health (MoPH) launched a long-term stewardship initiative to oversee and regulate private providers and align the sector with national health goals. AIM: We examine the progress the MoPH has made towards more effective stewardship, consider the challenges and assess the early impacts on for-profit performance. METHODS: We reviewed publicly available documents, publications and the grey literature to analyse the development, adoption and implementation of strategies, policies and regulations. We carried out a series of key informant/participant interviews, organizational capacity assessments and analyses of hospital standards checklists. Using a literature review of health systems strengthening, we proposed an Afghan-specific definition of six key stewardship functions to assess progress towards MoPH stewardship objectives. RESULTS: The MoPH and its partners have achieved positive results in strengthening its private sector stewardship functions especially in generating actionable intelligence and establishing strategic policy directions, administrative structures and a legal and regulatory framework. Progress has also been made on improving accountability and transparency, building partnerships and applying minimum required standards to private hospitals. Procedural and operational issues still need resolution and the MoPH is establishing mechanisms for resolving them. CONCLUSIONS: The MoPH stewardship initiative is notable for its achievements to date under challenging circumstances. Its success is due to the focus on developing a solid policy framework and building institutions and systems aimed at ensuring higher quality private services, and a rational long-term and sustainable role for the private sector. Although the MoPH stewardship initiative is still at an early stage, the evidence suggests that enhanced stewardship functions in the MoPH are leading to a more efficient and effective for-profit private sector. These successful early efforts offer high-leverage potential to rapidly scale up going forward.

Partnerships for Policy Development: A Case Study From Uganda's Costed Implementation Plan for Family Planning.

In global health, partnerships between practitioners and policy makers facilitate stakeholders in jointly addressing those issues that require multiple perspectives for developing, implementing, and evaluating plans, strategies, and programs. For family planning, costed implementation plans (CIPs) are developed through a strategic government-led consultative process that results in a detailed plan for program activities and an estimate of the funding required to achieve an established set of goals. Since 2009, many countries have developed CIPs. Conventionally, the CIP approach has not been defined with partnerships as a focal point; nevertheless, cooperation between key stakeholders is vital to CIP development and execution. Uganda launched a CIP in November 2014, thus providing an opportunity to examine the process through a partnership lens. This article describes Uganda's CIP development process in detail, grounded in a framework for assessing partnerships, and provides the findings from 22 key informant interviews. Findings reveal strengths in Uganda's CIP development process, such as willingness to adapt and strong senior management support. However, the evaluation also highlighted challenges, including district health officers (DHOs), who are a key group of implementers, feeling excluded from the development process. There was also a lack of planning around long-term partnership practices that could help address anticipated execution challenges. The authors recommend that future CIP development efforts use a long-term partnership strategy that fosters accountability by encompassing both the short-term goal of developing the CIP and the longer-term goal of achieving the CIP objectives. Although this study focused on Uganda's CIP for family planning, its lessons have implications for any policy or strategy development efforts that require multiple stakeholders to ensure successful execution.

Did Equity of Reproductive and Maternal Health Service Coverage Increase during the MDG Era? An Analysis of Trends and Determinants across 74 Low- and Middle-Income Countries.

INTRODUCTION: Despite widespread gains toward the 5th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. As countries enter the post-MDG era and strive toward UHC, it will be important to monitor the extent to which countries are achieving equity of RH and MH service coverage. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country's progress, or lack thereof, toward more equitable RH and MH service coverage. METHODS: We used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014. We examined trends in both relative and absolute equity, and measured relative equity using a concentration index of coverage data grouped by wealth quintile. Through multivariate analysis we examined the relative importance of policy factors, such as political commitment to health, governance, and the level of prepayment, in determining countries' progress toward greater equity in RH and MH service coverage. RESULTS: Relative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity. CONCLUSION: Equity in RH and MH service coverage has improved but varies considerably across countries and over time. Even among the subset of countries that are close to achieving the MDGs, progress made on equity varies considerably across countries. Enduring disparities in access and outcomes underpin mounting support for targeted reforms within the broader context of universal health coverage (UHC).

Creating conditions for greater private sector participation in achieving contraceptive security.

The growing gap between donor/government funding and the expected need for contraceptives is an issue of great concern for most developing countries. Addressing this resource shortfall, and meeting the goals of contraceptive security requires that countries mobilize the full and active participation of the private sector in the contraceptive market. Private sector involvement will not only increase the resource base available for contraceptives, it can also free up scarce donor and government resources to serve those who have the greatest need for public subsidies. This paper provides an overview of policy processes, strategies, and tools that can be used in developing countries to create an enabling environment for greater private sector participation, foster complementary public-private sector roles, and enhance the contribution of the private sector to contraceptive security.

Reproductive and child health accounts: an application to Rajasthan.

This paper describes resource flows for reproductive and child health (RCH) in the health care system of Rajasthan, India, using the integrating framework of health accounts. It analyzes sources and uses of RCH funds by provider and expenditure category. The paper provides policy options for redirecting current public and private expenditures to improve RCH indicators. Comparisons of the share of government expenditure in state gross domestic product (31%), of Rajasthan state government spending as a share of total health spending (21%) and of Rajasthan state government spending as a share of reproductive and child health spending (3%) suggest that there are imbalances to correct. Even a very large increase in RCH spending by the Government of Rajasthan, an increase bringing its share of RCH total spending up to the level of its share in health spending, would add only one percentage point to the state budget. The principal result of such an increase in public RCH spending would be a substantial reduction in currently high levels of fertility and of mortality among infants, children and women of reproductive age.