Direct patient costs for drugs and consumables at fifteen health facilities in Southern Madagascar, a secondary analysis of patient invoices.

BACKGROUND: Financial risk protection in health is a key objective of the Sustainable Development Goals. However, financial risk protection mechanisms are limited, especially in low-income countries, such as Madagascar. To design effective financial risk protection mechanisms, solid and reliable data on the costs patients incur when seeking care are essential. With this study, we therefore aim to describe medical costs for drugs and consumables for patients as well as model the likelihood of catastrophic health expenditure at fifteen health facilities in Southern Madagascar. METHODS: We conducted a costing analysis of patient invoices from fifteen health facilities (four primary and eleven secondary facilities) in Southern Madagascar, including public, private, and faith-based facilities. We included invoices from patients accessing care for life-threatening conditions, accidents and injuries, paediatric, or maternity care between February 2021 and July 2022. Costing data were limited to costs for drugs and consumables. We used regional household expenditure data from a representative household survey to calculate the incidence of catastrophic health expenditure in our sample. RESULTS: We analysed data from 9,855 cases, including 4,980 outpatient cases, 3,447 inpatient cases without surgical intervention, and 1,419 surgical cases. The average patient cost for drugs and medical consumables across all cases was USD 39.52 (range: USD 0.13-1,381.18, IQR: USD 9.07-46.91). Average costs for surgical treatment were USD 119.33 (range: USD 8.10-522.88, IQR: USD 73.81-160.49), for inpatient treatment USD 47.07 (range: USD 1.82-1,381.19, IQR: USD 22.38-58.91), and for outpatient treatment USD 11.73 (range: USD 0.15-207.79, IQR USD: 6.00-15.53). On average patients at faith-based facilities paid USD 47.20 (range: USD 0.49-530.33, IQR: 10.74-58.54), USD19.47 (range: USD 0.40-1,381.23, IQR: 6.77-24.07) at private facilities, and USD 34.65 (range: USD 0.58-245.24, IQR: USD 6.08-60.11) at public facilities. Patients requiring surgical care were most likely to experience catastrophic health expenditure and average costs for maternity care were significantly higher than for other patient groups. CONCLUSIONS: Financial risk protection schemes in Madagascar, such as the national UHC policy, and the national solidarity fund, as well as interventions by non-governmental and multilateral organisations, need to focus on surgical cases and maternity care to protect vulnerable populations from catastrophic health expenditures for life-threatening conditions, accidents and injuries, and maternity and paediatric care.

A cross-sectional analysis of the effectiveness of a nutritional support programme for people with tuberculosis in Southern Madagascar using secondary data from a non-governmental organisation.

BACKGROUND: There is a strong, bi-directional link between tuberculosis (TB) and undernutrition: TB often causes undernutrition, and undernourished people are more likely to contract TB and experience worse outcomes. Globally, several TB nutritional support programmes exist; however, evidence on their effectiveness is limited and contested. This study evaluates the effect of a nutritional support programme implemented for people with TB in the Atsimo-Andrefana region, Madagascar in 2022. Within this programme, undernourished people with TB [with a body mass index (BMI) of < 18.5 kg/m2] receive 0.6 L of vegetable oil and 6.0 kg of a soy-wheat blend per month throughout their TB treatment. METHODS: We analysed secondary non-governmental organisation data collected between January and November 2022 in the Atsimo-Andrefana region, Southern Madagascar, including information on an individual's medical conditions (e.g., type of TB, treatment outcomes) and nutritional status measured prior to, during, and after completion of treatment (e.g., height, weight, mid-upper arm circumference). We conducted descriptive analyses of patient baseline characteristics and outcomes to assess the impact of the provided nutritional support on the BMI of people with TB. RESULTS: A total of 1310 people with TB were included in the study [9.9% (130) children under the age of 5, 32.1% (420) children between 5 and 18 years, 58.0% (760) adults]. 55.4% of children under 5, 28.1% of children between ages 5 and 18, and 81.3% of adults were undernourished at treatment initiation. 42.3% (55/130) of children under 5 experienced severe acute malnutrition at treatment uptake. While the average BMI of adults with TB receiving food support increased over time, from 17.1 kg/m2 (interquartile range: 15.8-18.3, range: 10.3-22.5) to 17.9 kg/m2 (interquartile range: 16.6-19.1, range: 11.9-24.1), most adults remained undernourished even after completing TB treatment. CONCLUSIONS: The current TB nutritional support programme falls short of sufficiently increasing the BMI of people with TB to overcome malnutrition. There is an urgent need to revise the nutritional support available for people with TB, particularly for children under 5.