Mapping and analysis of health financing in South Kivu province (DRC) / Cartographie et analyse du financement de la santé dans la province du Sud-Kivu (RDC)

Introduction: In South-Kivu, the health system is underfunded due to numerous constraints. Several initiatives have been tested but are insufficient for increasing and sustaining health financing. Purpose of research: Analyze the health financing system in South-Kivu, through a mapping as well as quantitative and qualitative analysis of health financing mechanisms. Results: The provincial health financing system is fragmented, with poorly coordinated mechanisms and interventions, leading to duplication of health system strengthening activities in addition to the absence of a mechanism for pooling external funding flows. Costs recovery (i.e. user fees) and external supports are the most widely used schemes while the government hardly contributes to the financing of the provincial health system. Mutual health insurance is supposed to improve access to health care, but its coverage is still extremely low. Results-Based Financing and free health care programs, fully financed by external donors, are irregular and insufficiently sustainable. Conclusions: It would be critical to implement a strategic purchasing model that is anchored in local institutions, owned by all stakeholders, and integrating all existing financing mechanisms, which could be supported by a common fund supporting the provincial health system. The "Single Contract" initiative developed to harmonize, pool, and sustain external programs, could be a good basis in this respect. This would involve strengthening policy dialogue, developing an investment case to support resource mobilization and implementing a joint monitoring and evaluation platform for disbursements led by the provincial health authorities.

Introduction: Au Sud-Kivu, en République démocratique du Congo, le système de santé est sous-financé dû à de nombreuses contraintes. Plusieurs initiatives ont été testées mais restent insuffisantes pour augmenter et pérenniser le financement de la santé. But de l'étude: Analyser le système de financement de la santé au Sud-Kivu, par une cartographie et une analyse quantitative et qualitative des mécanismes de financement. Résultats: Le système de financement de la santé de la province est fragmenté, avec des mécanismes et interventions peu coordonnés, suscitant des duplications d'activités d'appui au système de santé, en plus de la quasi-absence de mécanisme de mise en commun des appuis extérieurs. Le recouvrement des coûts et les financements extérieurs sont les mécanismes les plus utilisés alors que l'État contribue très faiblement au financement du système provincial de santé. Les mutuelles de santé sont censées améliorer l'accès aux soins, mais leur taux de couverture reste extrêmement faible. Le financement basé sur les résultats et la gratuité des soins, intégralement compensés par les donateurs extérieurs, sont irréguliers et insuffisamment pérennes. Conclusions: Il serait essentiel d'adopter au Sud-Kivu un modèle d'achat stratégique, ancré dans les institutions locales, approprié par l'ensemble des parties prenantes, qui intègre l'ensemble des mécanismes de financement existants et qui soit appuyé par un fonds commun d'appui au système provincial de santé. L'initiative du Contrat unique développée pour harmoniser, mettre en commun et pérenniser les programmes extérieurs peut servir de base pour élaborer un tel modèle. Ceci impliquerait de renforcer le dialogue politique, d'élaborer un dossier d'investissement pour soutenir la mobilisation des ressources et de créer une plateforme conjointe de suivi et d'évaluation des décaissements, pilotée par les autorités provinciales de santé.

Measuring equity of access to eye health outreach camps in rural Malawi.

INTRODUCTION: Equity in the access and use of health services is critical if countries are to make progress towards universal health coverage and address the systematic exclusion of the most vulnerable groups. The purpose of this study was to assess if the Co-ordinated Approach To Community Health programme implemented by Sightsavers was successful in reaching the poorest population, women, and people living with disabilities in Kasungu district, Malawi. METHODS: Between April and September 2017, data on socio-economic status, household characteristics and functional disability were collected from patients attending at eye camps in Kasungu district, Malawi. Using asset-based tools to measure household wealth (EquityTool© and Simple Poverty Scorecard©) and the Washington Group Short Set of Questions, individuals were categorised by wealth quintiles, poverty status, and functional disability status and then compared to relevant representative national household surveys. In addition, a follow-up household survey was conducted to check the validity of self-reported household characteristics at eye camps. RESULTS: A total of 1,358 individuals participated in the study. The study shows that self-reported data on household characteristics and assets are reliable and can be collected in clinical settings (instead of relying on direct observations of assets). Individuals attending outreach camps were poorer in terms of relative wealth and absolute poverty rates compared to the rest of the population in Kasungu. It was estimated that 9% of the participants belonged to the poorest quintile compared to 4% for the population in Kasungu (DHS 2015-2016). The ultra-poverty rate was also lower among respondents (13%) compared to 15% for Kasungu district (IHS 2017). The functional disability rate was 27.5% for study participants, and statistically higher than the general population (5.6%, SENTIF 2017). Even though women are more at risks than men, 54% of the participants were men. CONCLUSIONS: Our study shows that existing tools can be reliably used, and combined, if based on recent population data, to assess equity of access to health services for vulnerable groups of the population. The findings suggest that the programme was successful in reaching the poorest people of the Kasungu district population as well as those with disabilities through outreach camps but that more men than women were reach through the programme. Subsequently, our study showed that self-reported household characteristics are a reliable method to measure asset-based wealth of camps' attendee. However, it is essential to use sub-national data (district or regional level) from recent surveys for the purpose of benchmarking in order to produce accurate results.

Cost and budget impact analysis of a school-based vision screening programme in Cambodia and Ghana: Implications for policy and programme scale-up.

Poor vision due to unaddressed refractive error in children is considered to be a public health problem in many low- and middle-income countries. Research shows that correcting refractive error with spectacles could have a positive impact on school attendance and academic performance for children. The aim of this study was to estimate the cost of integrating vision screening and provision of spectacles in existing school health programmes in Cambodia and Ghana. Budget impact analysis of the intervention scale up is also reported, including univariate and multivariate sensitivity analyses. This study suggests that the scale up of school-based vision screening programmes is affordable in resource limited settings, such as Cambodia and Ghana, considering the current education budgets, and providing there is sufficient in-country capacity to deliver such interventions at scale. The study highlights several policy and programme implications and provides suggestions for minimising costs and maximising efficiencies of vision screening in a school setting. Findings from this analysis can help education planners and international partners to improve their planning and budgeting processes for school-based interventions to improve health and learning outcomes for children in low- and middle-income countries.

Prevalence of Visual Impairment and Coverage of Cataract Surgical Services: Associations with Sex, Disability, and Economic Status in Five Diverse Sites.

PURPOSE: Prevalence of visual impairment (VI) and access to services can vary significantly across and between different population groups. With renewed focus on universal health coverage and leaving no one behind, it is important to understand factors driving inequitable eye health. This paper presents results from five population-based surveys where prevalence of VI and cataract surgical coverage (CSC) were measured and examined for differences by sex, economic-status, and disability. METHODS: Rapid assessments of avoidable blindness took place in four rural sites: Kalahandi, Jhabua and Sitapur in India; and Singida, Tanzania; and one urban site: Lahore, Pakistan. In addition, the Equity Tool was used to measure economic status and the Washington Group Short Set was used to measure disability. Prevalence of VI and CSC were calculated and associations with sex, disability, and relative wealth examined. RESULTS: Prevalence of VI varied from 1.9% in Lahore to 15.0% in Kalahandi. CSC varied from 39.1% in Singida to 84.0% in Lahore. Additional disability was associated with greater levels of VI in all sites and lower CSC in Singida. Being female was associated with higher VI in Kalahandi, Lahore and Singida and lower CSC in Lahore and Singida. Being poorer was associated with higher VI in Singida and lower CSC in Singida and Sitapur. CONCLUSION: Relationships between VI and relative wealth, sex, and disability are complex and variable. Although certain characteristics may be associated with lower coverage or worse outcomes, they cannot be generalized and local data are vital to tailor services to achieve good coverage.

Willingness to Pay for Cataract Surgeries Among Patients Visiting Eye Care Facilities in Dhaka, Bangladesh.

BACKGROUND: Cataract is the leading cause of avoidable blindness globally. It is estimated that 89% of people with visual impairment live in low- and middle-income countries where the cost of cataract surgery represents a major barrier for accessing these services. Developing self-sustaining healthcare programs to cater the unmet demands warrants a better understanding of patients' willingness to pay (WTP) for their services. OBJECTIVES: Using a sample of patients visiting eye care facilities in Dhaka, Bangladesh, we estimate WTP for two different cataract extraction techniques, namely small incision cataract surgery (SICS) and phacoemulsification. METHODS: We used contingent valuation (CV) approach and elicited WTP through double-bounded dichotomous choice experiments. We interviewed 556 randomly selected patients (283 for SICS and 273 for phacoemulsification) from five different eye care hospitals of Dhaka. In this paper, we estimated the mean and marginal WTP using interval regression models. We also compared the estimated WTP and stated demand for cataract surgeries against the prevailing market prices of SICS and phacoemulsification. RESULTS: We found the mean WTP of BDT 7579 (US$93) for SICS and BDT 10,208 (US$126) for phacoemulsification are equivalent to 12 and 16 days of household income, respectively. Household income and assets appeared as the major determinants of WTP for cataract surgeries. However, we did not find any significant association with gender, occupation, and household size among other socioeconomic characteristics. Comparisons between market prices and average WTP suggest it is possible to have a viable market for SICS, but a subsidy-based model for phacoemulsification will be financially challenging because of low WTP and high costs. CONCLUSION: Our findings suggest lower-cost SICS can potentially provide patients access to surgeries to treat cataract conditions. Moreover, price discrimination and cross-subsidization could be a viable strategy to increase the service-uptake as well as ensure financial sustainability.

The cost of mapping trachoma: Data from the Global Trachoma Mapping Project.

BACKGROUND: The Global Trachoma Mapping Project (GTMP) was implemented with the aim of completing the baseline map of trachoma globally. Over 2.6 million people were examined in 1,546 districts across 29 countries between December 2012 and January 2016. The aim of the analysis was to estimate the unit cost and to identify the key cost drivers of trachoma prevalence surveys conducted as part of GTMP. METHODOLOGY AND PRINCIPAL FINDINGS: In-country and global support costs were obtained using GTMP financial records. In-country expenditure was analysed for 1,164 districts across 17 countries. The mean survey cost was $13,113 per district [median: $11,675; IQR = $8,365-$14,618], $17,566 per evaluation unit [median: $15,839; IQR = $10,773-$19,915], $692 per cluster [median: $625; IQR = $452-$847] and $6.0 per person screened [median: $4.9; IQR = $3.7-$7.9]. Survey unit costs varied substantially across settings, and were driven by parameters such as geographic location, demographic characteristics, seasonal effects, and local operational constraints. Analysis by activities showed that fieldwork constituted the largest share of in-country survey costs (74%), followed by training of survey teams (11%). The main drivers of in-country survey costs were personnel (49%) and transportation (44%). Global support expenditure for all surveyed districts amounted to $5.1m, which included grant management, epidemiological support, and data stewardship. CONCLUSION: This study provides the most extensive analysis of the cost of conducting trachoma prevalence surveys to date. The findings can aid planning and budgeting for future trachoma surveys required to measure the impact of trachoma elimination activities. Furthermore, the results of this study can also be used as a cost basis for other disease mapping programmes, where disease or context-specific survey cost data are not available.

Socioeconomic aspects of neglected tropical diseases.

Although many examples of highly cost-effective interventions to control neglected tropical diseases exist, our understanding of the full economic effect that these diseases have on individuals, households, and nations needs to be improved to target interventions more effectively and equitably. We review data for the effect of neglected tropical diseases on a population's health and economy. We also present evidence on the costs, cost-effectiveness, and financing of strategies to monitor, control, or reduce morbidity and mortality associated with these diseases. We explore the potential for economies of scale and scope in terms of the costs and benefits of successfully delivering large-scale and integrated interventions. The low cost of neglected tropical disease control is driven by four factors: the commitment of pharmaceutical companies to provide free drugs; the scale of programmes; the opportunities for synergising delivery modes; and the often non-remunerated volunteer contribution of communities and teachers in drug distribution. Finally, we make suggestions for future economic research.