Delivering reproductive health services through non-state providers in Pakistan: understanding the value for money of different approaches.

BACKGROUND: Delivering Reproductive Health Results(DRHR) programme used social franchising (SF) and social marketing (SM) approaches to increase the supply of high quality family planning services in underserved areas of Pakistan. We assessed the costs, cost-efficiency and cost-effectiveness of DRHR to understand the value for money of these approaches. METHODS: Financial and economic programme costs were calculated. Costs to individual users were captured in a pre-post survey. The cost per couple years of protection (CYP) and cost per new user were estimated as indicators of cost efficiency. For the cost-effectiveness analysis we estimated the cost per clinical outcome averted and the cost per disability-adjusted life year (DALY) averted. RESULTS: Approximately £20 million were spent through the DRHR programme between July 2012 and September 2015 on commodities and services representing nearly four million CYPs. Based on programme data, the cumulative cost-efficiency of the entire DRHR programme was £4.8 per CYP. DRHR activities would avert one DALY at the cost of £20. Financial access indicators generally improved in programme areas, but the magnitude of progress varies across indicators. CONCLUSIONS: The SF and SM approaches adopted in DRHR appear to be cost effective relative to comparable reproductive health programmes. This paper adds to the limited evidence on the cost-effectiveness of different models of reproductive health care provision in low- and middle-income settings. Further studies are needed to nuance the understanding of the determinants of impact and value for money of SF and SM.

Costs of hospitalization with respiratory syncytial virus illness among children aged <5 years and the financial impact on households in Bangladesh, 2010.

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of acute respiratory illness in young children and results in significant economic burden. There is no vaccine to prevent RSV illness but a number of vaccines are in development. We conducted this study to estimate the costs of severe RSV illness requiring hospitalization among children <5 years and associated financial impact on households in Bangladesh. Data of this study could be useful for RSV vaccine development and also the value of various preventive strategies, including use of an RSV vaccine in children if one becomes available. METHODS: From May through October 2010, children aged <5 years with laboratory-confirmed RSV were identified from a sentinel influenza program database at four tertiary hospitals. Research assistants visited case-patients' homes after hospital discharge and administered a structured questionnaire to record direct medical costs (physician consultation fee, costs for hospital bed, medicines and diagnostic tests); non-medical costs (costs for food, lodging and transportation); indirect costs (caregivers' productivity loss), and coping strategies used by families to pay for treatment. We used WHO-Choice estimates for routine health care service costs. We added direct, indirect and health care service costs to calculate cost-per-episode of severe RSV illness. We used Monte Carlo simulation to estimate annual economic burden for severe RSV illness. FINDINGS: We interviewed caregivers of 39 persons hospitalized for RSV illness. The median direct cost for hospitalization was US$ 62 (interquartile range [IQR] = 43-101), indirect cost was US$ 19 (IQR = 11-29) and total cost was US$ 94 (IQR = 67-127). The median out-of-pocket cost was 24% of monthly household income of affected families (US$ 143), and >50% families borrowed money to meet treatment cost. We estimated that the median direct cost of RSV-associated hospitalization in children aged <5 years in Bangladesh was US$ 10 million (IQR: US$ 7-16 million), the median indirect cost was US$ 3.0 million (IQR: 2-5 million) in 2010. CONCLUSION: RSV-associated hospitalization among children aged <5 years represents a substantial economic burden in Bangladesh. Affected families frequently incurred considerable out of pocket and indirect costs for treatment that resulted in financial hardship.

Family caregivers in public tertiary care hospitals in Bangladesh: risks and opportunities for infection control.

BACKGROUND: Family caregivers are integral to patient care in Bangladeshi public hospitals. This study explored family caregivers' activities and their perceptions and practices related to disease transmission and prevention in public hospitals. METHODS: Trained qualitative researchers conducted a total of 48 hours of observation in 3 public tertiary care hospitals and 12 in-depth interviews with family caregivers. RESULTS: Family caregivers provided care 24 hours a day, including bedside nursing, cleaning care, and psychologic support. During observations, family members provided 2,065 episodes of care giving, 75% (1,544) of which involved close contact with patients. We observed family caregivers washing their hands with soap on only 4 occasions. The majority of respondents said diseases are transmitted through physical contact with surfaces and objects that have been contaminated with patient secretions and excretions, and avoiding contact with these contaminated objects would help prevent disease. CONCLUSION: Family caregivers are at risk for hospital-acquired infection from their repeated exposure to infectious agents combined with their inadequate hand hygiene and knowledge about disease transmission. Future research should explore potential strategies to improve family caregivers' knowledge about disease transmission and reduce family caregiver exposures, which may be accomplished by improving care provided by health care workers.

Rates of hospital-acquired respiratory illness in Bangladeshi tertiary care hospitals: results from a low-cost pilot surveillance strategy.

BACKGROUND: Patients hospitalized in resource-poor health care settings are at increased risk for hospital-acquired respiratory infections due to inadequate infrastructure. METHODS: From 1 April 2007 through 31 March 2008, we used a low-cost surveillance strategy to identify new onset of respiratory symptoms in patients hospitalized for >72 h and in health care workers in medicine and pediatric wards at 3 public tertiary care hospitals in Bangladesh. RESULTS: During 46,273 patient-days of observation, we recorded 136 episodes of hospital-acquired respiratory disease, representing 1.7% of all patient hospital admissions; rates by ward ranged from 0.8 to 15.8 cases per 1000 patient-days at risk. We identified 22 clusters of respiratory disease, 3 of which included both patients and health care workers. Of 226 of heath care workers who worked on our surveillance wards, 61 (27%) experienced a respiratory illness during the study period. The cost of surveillance was US$43 per month per ward plus 30 min per day in data collection. CONCLUSIONS: Patients on these study wards frequently experienced hospital-acquired respiratory infections, including 1 in every 20 patients hospitalized for >72 h on 1 ward. The surveillance method was useful in calculating rates of hospital-acquired respiratory illness and could be used to enhance capacity to quickly detect outbreaks of respiratory disease in health care facilities where systems for outbreak detection are currently limited and to test interventions to reduce transmission of respiratory pathogens in resource-poor settings.