Unit Costing of Health Extension Worker Activities in Ethiopia: A Model for Managers at the District and Health Facility Level.

BACKGROUND: Over the last decade, Ethiopia has made impressive national improvements in health outcomes, including reductions in maternal, neonatal, infant, and child mortality attributed in large part to their Health Extension Program (HEP). As this program continues to evolve and improve, understanding the unit cost of health extension worker (HEW) services is fundamental to planning for future growth and ensuring adequate financial support to deliver effective primary care throughout the country. METHODS: We sought to examine and report the data needed to generate a HEW fee schedule that would allow for full cost recovery for HEW services. Using HEW activity data and estimates from national studies and local systems we were able to estimate salary costs and the average time spent by an HEW per patient/community encounter for each type of services associated with specific users. Using this information, we created separate fee schedules for activities in urban and rural settings with two estimates of non-salary multipliers to calculate the total cost for HEW services. RESULTS: In the urban areas, the HEW fees for full cost recovery of the provision of services (including salary, supplies, and overhead costs) ranged from 55.1 birr to 209.1 birr per encounter. The rural HEW fees ranged from 19.6 birr to 219.4 birr. CONCLUSION: Efforts to support health system strengthening in low-income settings have often neglected to generate adequate, actionable data on the costs of primary care services. In this study, we have combined time-motion and available financial data to generate a fee schedule that allows for full cost recovery of the provision of services through billable health education and service encounters provided by Ethiopian HEWs. This may be useful in other country settings where managers seek to make evidence-informed planning and resource allocation decisions to address high burden of disease within the context of weak administrative data systems and severe financial constraints.

The added value of a mobile application of Community Case Management on referral, re-consultation and hospitalization rates of children aged under 5 years in two districts in Northern Malawi: study protocol for a pragmatic, stepped-wedge cluster-randomized controlled trial.

BACKGROUND: There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi. METHODS/DESIGN: This is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017. DISCUSSION: This is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02763345 . Registered on 3 May 2016.

Contextual variations in costs for a community health strategy implemented in rural, peri-urban and nomadic sites in Kenya.

BACKGROUND: Many low and middle income countries have developed community health strategies involving lay health workers, to complement and strengthen public health services. This study explores variations in costing parameters pertinent to deployment of community health volunteers across different contexts outlining considerations for costing program scale-up. METHODS: The study used quasi experimental study design and employed both quantitative and qualitative methods to explore community health unit implementation activities and costs and compare costs across purposively selected sites that differed socially, economically and ecologically. Data were collected from November 2010 to December 2013 through key informant interviews and focus group discussions. We interviewed 16 key informants (eight District community health strategy focal persons, eight frontline field officers), and eight focus group discussions (four with community health volunteers and four with community health committee) and 560 sets of monthly cost data. Cost data were tabulated using Microsoft Excel. Qualitative data were transcribed and coded using a content analysis framework. RESULTS: Four critical elements: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits, drove cost variations across the three sites. Attrition rate was highest in peri-urban site where population is highly mobile and lowest in nomadic site. More households were covered by community health workers in the peri-urban area making per capita costs considerably less than in the nomadic settings where long distances had to be covered to reach sparsely distributed households. Livelihood opportunity costs for Community Health Volunteers were highest in nomadic setting, while peri-urban ones reported substantial employability benefits resulting from training. Social opportunity benefits were highest in rural site. CONCLUSIONS: Results show that costs of implementing community health strategy varied due to different area contextual factors in Kenya. This study identified four critical elements that drive cost variations: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits. Health programme managers and policy-makers need to pay attention to details of contextual factors in costing for effective implementation of community health strategies.

Economic evaluation of Indigenous health worker management of poorly controlled type 2 diabetes in north Queensland.

OBJECTIVE: To conduct an economic evaluation of intensive management by Indigenous health workers (IHWs) of Indigenous adults with poorly controlled type 2 diabetes in rural and remote north Queensland. DESIGN: Cost-consequence analysis alongside a cluster randomised controlled trial of an intervention delivered between 1 March 2012 and 5 September 2013. SETTING: Twelve primary health care services in rural and remote north Queensland communities with predominantly Indigenous populations. PARTICIPANTS: Indigenous adults with poorly controlled type 2 diabetes (HbA1c ≥ 69 mmol/mol) and at least one comorbidity (87 people in six IHW-supported communities (IHW-S); 106 in six usual care (UC) communities). MAIN OUTCOME MEASURES: Per person cost of the intervention; differential changes in mean HbA1c levels, percentage with extremely poor HbA1c level control, quality of life, disease progression, and number of hospitalisations. RESULTS: The mean cost of the 18-month intervention trial was $10 060 per person ($6706 per year). The intervention was associated with a non-significantly greater reduction in mean HbA1c levels in the IHW-S group (-10.1 mmol/mol v -5.4 mmol/mol in the UC group; P = 0.17), a significant reduction in the proportion with extremely poor diabetes control (HbA1c ≥ 102 mmol/mol; P = 0.002), and a sub-significant differential reduction in hospitalisation rates for type 2 diabetes as primary diagnosis (-0.09 admissions/person/year; P = 0.06), with a net reduction in mean annual hospital costs of $646/person (P = 0.07). Quality of life utility scores declined in both groups (between-group difference, P = 0.62). Rates of disease progression were high in both groups (between-group difference, P = 0.73). CONCLUSION: Relative to the high cost of the intervention, the IHW-S model as implemented is probably a poor investment. Incremental cost-effectiveness might be improved by a higher caseload per IHW, a longer evaluation time frame, and improved service integration. Further approaches to improving chronic disease outcomes in this very unwell population need to be explored, including holistic approaches that address the complex psychosocial, pathophysiological and environmental problems of highly disadvantaged populations. TRIAL REGISTRATION: ANZCTR12610000812099.

Predictors of Essential Health and Nutrition Service Delivery in Bihar, India: Results From Household and Frontline Worker Surveys.

BACKGROUND: In Bihar, India, coverage of essential health and nutrition interventions is low. These interventions are provided by 2 national programs--the Integrated Child Development Services (ICDS) and Health/National Rural Health Mission (NRHM)--through Anganwadi workers (AWWs) and Accredited Social Health Activists (ASHAs), respectively. Little is known, however, about factors that predict effective service delivery by these frontline workers (FLWs) or receipt of services by households. This study examined the predictors of use of 4 services: (1) immunization information and services, (2) food supplements, (3) pregnancy care information, and (4) general nutrition information. METHODS: Data are from a 2012 cross-sectional survey of 6,002 households in 400 randomly selected villages in 1 district of Bihar state, as well as an integrated survey of 377 AWWs and 382 ASHAs from the same villages. For each of the 4 service delivery outcomes, logistic regression models were specified using a combination of variables hypothesized to be supply- and demand-side drivers of service utilization. RESULTS: About 35% of households reported receiving any of the 4 services. Monetary immunization incentives for AWWs (OR = 1.55, CI = 1.02-2.36) and above-median household head education (OR = 1.39, CI = 1.05-1.82) were statistically significant predictors of household receipt of immunization services. Higher household socioeconomic status was associated with significantly lower odds of receiving food supplements (OR = 0.87, CI = 0.79-0.96). ASHAs receiving incentives for institutional delivery (OR = 1.52, CI = 0.99-2.33) was marginally associated with higher odds of receiving pregnancy care information, and ASHAs who maintained records of pregnant women was significantly associated with households receiving such information (OR = 2.25, CI = 1.07-4.74). AWWs receiving immunization incentives was associated with significantly higher odds of households receiving general nutrition information (OR = 1.92, CI = 1.08-3.41), suggesting a large spillover effect of incentives from product- to information-oriented services. CONCLUSION: Product-oriented incentives affect delivery of both product- and information-oriented services, although household factors are also important. In India, existing government programs can mitigate supply- and demand-side constraints to receiving essential interventions by optimizing existing incentives for FLWs in national programs, helping FLWs better organize their work, and raising awareness among groups who are less likely to access services.

Evaluating the effect of innovative motivation and supervision approaches on community health worker performance and retention in Uganda and Mozambique: study protocol for a randomised controlled trial.

BACKGROUND: If trained, equipped and utilised, community health workers (CHWs) delivering integrated community case management for sick children can potentially reduce child deaths by 60%. However, it is essential to maintain CHW motivation and performance. The inSCALE project aims to evaluate, using a cluster randomised controlled trial, the effect of interventions to increase CHW supervision and performance on the coverage of appropriate treatment for children with diarrhoea, pneumonia and malaria. METHODS/DESIGN: Participatory methods were used to identify best practices and innovative solutions. Quantitative community based baseline surveys were conducted to allow restricted randomisation of clusters into intervention and control arms. Individual informed consent was obtained from all respondents. Following formative research and stakeholder consultations, two intervention packages were developed in Uganda and one in Mozambique. In Uganda, approximately 3,500 CHWs in 39 clusters were randomised into a mobile health (mHealth) arm, a participatory community engagement arm and a control arm. In Mozambique, 275 CHWs in 12 clusters were randomised into a mHealth arm and a control arm. The mHealth interventions encompass three components: 1) free phone communication between users; 2) data submission using phones with automated feedback, messages to supervisors for targeted supervision, and online data access for district statisticians; and 3) motivational messages. The community engagement arm in Uganda established village health clubs seeking to 1) improve the status and standing of CHWs, 2) increase demand for health services and 3) communicate that CHWs' work is important. Process evaluation was conducted after 10 months and end-line surveys will establish impact after 12 months in Uganda and 18 months in Mozambique. Main outcomes include proportion of sick children appropriately treated, CHW performance and motivation, and cost effectiveness of interventions. DISCUSSION: Study strengths include a user-centred design to the innovations, while weaknesses include the lack of a robust measurement of coverage of appropriate treatment. Evidence of cost-effective innovations that increase motivation and performance of CHWs can potentially increase sustainable coverage of iCCM at scale. TRIAL REGISTRATION: (identifier NCT01972321 ) on 22 April 22 2013.

Redesigning primary care to tackle the global epidemic of noncommunicable disease.

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

'Trust and teamwork matter': community health workers' experiences in integrated service delivery in India.

A comprehensive and integrated approach to strengthen primary health care has been the major thrust of the National Rural Health Mission (NRHM) that was launched in 2005 to revamp India's rural public health system. Though the logic of horizontal and integrated health care to strengthen health systems has long been acknowledged at policy level, empirical evidence on how such integration operates is rare. Based on recent (2011-2012) ethnographic fieldwork in Odisha, India, this article discusses community health workers' experiences in integrated service delivery through village-level outreach sessions within the NRHM. It shows that for health workers, the notion of integration goes well beyond a technical lens of mixing different health services. Crucially, they perceive 'teamwork' and 'building trust with the community' (beyond trust in health services) to be critical components of their practice. However, the comprehensive NRHM primary health care ideology - which the health workers espouse - is in constant tension with the exigencies of narrow indicators of health system performance. Our ethnography shows how monitoring mechanisms, the institutionalised privileging of statistical evidence over field-based knowledge and the highly hierarchical health bureaucratic structure that rests on top-down communications mitigate efforts towards sustainable health system integration.

Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review.

BACKGROUND: Each year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings. METHODS: A systematic review was undertaken on the cost-effectiveness of strategies to improve the demand and supply of maternal and newborn health care in low-income and lower-middle-income countries. Peer-reviewed and grey literature published since 1990 was searched using bibliographic databases, websites of selected organizations, and reference lists of relevant studies and reviews. Publications were eligible for inclusion if they report on a behavioural or health systems strategy that sought to improve the utilization or provision of care during pregnancy, childbirth or the neonatal period; report on its cost-effectiveness; and were set in one or more low-income or lower-middle-income countries. The quality of the publications was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. Incremental cost per life-year saved and per disability-adjusted life-year averted were compared to gross domestic product per capita. RESULTS: Forty-eight publications were identified, which reported on 43 separate studies. Sixteen were judged to be of high quality. Common themes were identified and the strategies were presented in relation to the continuum of care and the level of the health system. There was reasonably strong evidence for the cost-effectiveness of the use of women's groups, home-based newborn care using community health workers and traditional birth attendants, adding services to routine antenatal care, a facility-based quality improvement initiative to enhance compliance with care standards, and the promotion of breastfeeding in maternity hospitals. Other strategies reported cost-effectiveness measures that had limited comparability. CONCLUSION: Demand and supply-side strategies to improve maternal and newborn health care can be cost-effective, though the evidence is limited by the paucity of high quality studies and the use of disparate cost-effectiveness measures. TRIAL REGISTRATION: PROSPERO_ CRD42012003255.

An implementation evaluation of a policy aiming to improve financial access to maternal health care in Djibo district, Burkina Faso.

BACKGROUND: To bring down its high maternal mortality ratio, Burkina Faso adopted a national health policy in 2007 that designed to boost the assisted delivery rate and improving quality of emergency obstetrical and neonatal care. The cost of transportation from health centres to district hospitals is paid by the policy. The worst-off are exempted from all fees. METHODS: The objectives of this paper are to analyze perceptions of this policy by health workers, assess how this health policy was implemented at the district level, identify difficulties faced during implementation, and highlight interactional factors that have an influence on the implementation process. A multiple site case study was conducted at 6 health centres in the district of Djibo in Burkina Faso. The following sources of data were used: 1) district documents (n = 23); 2) key interviews with district health managers (n = 10), health workers (n = 16), traditional birth attendants (n = 7), and community management committees (n = 11); 3) non-participant observations in health centres; 4) focus groups in communities (n = 62); 5) a feedback session on the findings with 20 health staff members. RESULTS: All the activities were implemented as planned except for completely subsidizing the worst-off, and some activities such as surveys for patients and the quality assurance service team aiming to improve quality of care. District health managers and health workers perceived difficulties in implementing this policy because of the lack of clarity on some topics in the guidelines. Entering the data into an electronic database and the long delay in reimbursing transportation costs were the principal challenges perceived by implementers. Interactional factors such as relations between providers and patients and between health workers and communities were raised. These factors have an influence on the implementation process. Strained relations between the groups involved may reduce the effectiveness of the policy. CONCLUSIONS: Implementation analysis in the context of improving financial access to health care in African countries is still scarce, especially at the micro level. The strained relations of the providers with patients and the communities may have an influence on the implementation process and on the effects of this health policy. Therefore, power relations between actors of the health system and the community should be taken into consideration. More studies are needed to better understand the influence of power relations on the implementation process in low-income countries.

Level and determinants of incentives for village midwives in Indonesia.

Since the early 1990s Indonesia has attempted to increase the level of skilled attendance at birth by placing rural midwives in every village in an effort to reduce persistently high levels of maternal mortality. Yet evidence suggests that there remains insufficient incentive to ensure an equal distribution across areas while the poor in all areas continue to access skilled attendance much less than those in richer groups. We report on a survey that was conducted as part of a complex evaluation of the rural midwife programme in Banten Province, to better understand the effect of financial incentives on the distribution of midwives and use of services. Midwives obtain almost two-thirds of their income from private clinical practice. Private income is strongly associated with competence and experience. Multivariate analysis suggests that midwives are well able to earn a substantial private income even in remoter areas. Yet the study also found a high level of unwillingness to move posts to a more remote area for a variety of non-financial reasons. The results suggest that the access to skilled attendance of those unable to afford fees may be impaired by the dependence on fee income, a result supported by companion household studies. In addition, ensuring that staff live and work in remoter areas is only likely to be financially sustainable if midwives can be attracted to live in these areas early in their careers. Finally, the overall strategy of basing skilled attendance mainly on village services throughout the country may need to be re-visited, with alternative models offered in areas where it continues to be impractical even with a change in the incentive framework.

The impact of a small steady stream of income for women on family health and economic well-being.

Our primary aim to evaluate the impact of a small steady stream of income on family health and well-being among rural women employed part-time in a health project in Sarlahi district, Nepal. All 870 women applying for the job of distributing nutritional supplements in their villages completed a questionnaire prior to selection for employment, 350 of whom were hired and 520 who were not. A total of 736 women completed a second questionnaire 2 years later, 341 (97.4%) of whom had been continuously employed during this period, and 395 (76.0%) who had never been employed by the project. Changes in health and well-being over 2 years were compared between women who were and were not hired. Women who were hired were younger and better educated, but were similar in other regards. After adjusting for selection differences, employed women were more likely to save cash, buy jewellery, and buy certain discretionary household goods over 2 years than those who were not hired. Expenditures on children's clothing increased more for employed women, and their children were more likely to be in private schools at follow-up, but there was no impact on health and survival of children. Women with a small steady stream of income did improve their personal economic situation by savings and increased expenditures for children and the household. Longer follow-up may reveal impacts on health access and expenditures, although these were not evident in 2 years of employment.

Cost-effectiveness of community health workers in tuberculosis control in Bangladesh.

OBJECTIVE: To compare the cost-effectiveness of the tuberculosis (TB) programme run by the Bangladesh Rural Advancement Committee (BRAC), which uses community health workers (CHWs), with that of the government TB programme which does not use CHWs. METHODS: TB control statistics and cost data for July 1996 - June 1997 were collected from both government and BRAC thanas (subdistricts) in rural Bangladesh. To measure the cost per patient cured, total costs were divided by the total number of patients cured. FINDINGS: In the BRAC and government areas, respectively, a total of 186 and 185 TB patients were identified over one year, with cure rates among sputum-positive patients of 84% and 82%. However, the cost per patient cured was US$ 64 in the BRAC area compared to US$ 96 in the government area. CONCLUSION: The government programme was 50% more expensive for similar outcomes. Although both the BRAC and government TB control programmes appeared to achieve satisfactory cure rates using DOTS (a five-point strategy), the involvement of CHWs was found to be more cost-effective in rural Bangladesh. With the same budget, the BRAC programme could cure three TB patients for every two in the government programme.

Integrated health programmes.

PIP: Over a period of 10 years, a hospital in rural Africa slowly built an integrated primary and secondary health care program to the point where it has more than 40 elements. In its initial stage (1982-84), hospital staff and community participants were trained, the number of mobile clinics was increased, community participation was sought, and health education was emphasized. During 1985-86, 92 village health committees were organized with 70 trained Village Health Workers (VHWs). This led to a rapid increase in vaccination rates, the use of oral rehydration therapy, and training of traditional birth attendants. In 1987-88, 14 VHW were trained to use basic medical kits and distribute medicines. By 1990, 18,000 of the 72,000 outpatient treatments were administered by VHWs. In 1987, the hospital made a community diagnosis and increased the size of its advisory board (which became 60% female). Because the community identified food, water, and poverty as its priorities, the hospital took steps to improve the food supply, the water supply, and the financial position of the women. In 1989-90, the primary health care (PHC) project added the components of family planning, a weaning food production unit, food coupons, food for work, grain banks, a trust fund, literacy classes, health stamps, a mobile malnutrition clinic, subsidized fertilizer and seed, low-cost care for victims of AIDS, new malaria treatment schedules, and a housing association. The PHC program has resulted in a reduction in under-five deaths from the national average of 330/1000 to 145/1000 (other areas have reduced deaths to 270-300/1000. The program is also becoming increasingly cost-effective, costing about 6 pounds per capita over 10 years for a population of 50,000. Country-wide implementation of the PHC program would require only 30% of the present health budget.^ieng