Internal contracting of health services in Cambodia: drivers for change and lessons learned after a decade of external contracting.

BACKGROUND: Since the late 1990s, contracting has been employed in Cambodia in an attempt to accelerate rural health system recovery and improve health service delivery. Special Operating Agencies (SOA), a form of 'internal contracting', was introduced into selected districts by the Cambodia Ministry of Health in 2009. This study investigates how the SOA model was implemented and identifies effects on service delivery, challenges in operation and lessons learned. METHODS: The study was carried out in four districts, using mixed methods. Key informant interviews were conducted with representatives of donors and the Ministry of Health. In-depth interviews were carried out with managers of SOA and health facilities and health workers from referral hospitals and health centres. Data from the Annual Health Statistic Report 2009-2012 on utilisation of antenatal care, delivery and immunisation were analysed. RESULTS: There are several challenges with implementation: limited capacity and funding for monitoring the SOA, questionable reliability of the monitoring data, and some facilities face challenges in achieving the targets set in their contracts. There are some positive effects on staff behaviour which include improved punctuality, being on call for 24 h service, and perceived better quality of care, promoted through adherence to work regulations stipulated in the contracts and provision of incentives. However, flexibility in enforcing these regulations in SOA has led to more dual practice, compared to previous contracting schemes. There are reported increases in utilization of services by the general population and the poor although the quantitative findings question the extent to which these increases are attributable to the contracting model. CONCLUSION: Capacity in planning and monitoring contracts at different levels in the health system is required. Service delivery will be undermined if effective performance management is not established nor continuously applied. Improvements in the implementation of SOA include: better monitoring by the central and provincial levels; developing incentive schemes that tackle the issues of dual practice; and securing trustworthy baseline data for performance indicators.

Where is Nepal in the nutrition transition?

BACKGROUND AND OBJECTIVE: Nutrition transition is rapid in developing countries, but Nepalese transition is relatively unknown. This study aimed to describe nutrition transition in Nepal over the past 40 years by identifying the shifts in the Nepalese diets and nutritional status and the underlying shifts associated with this. METHODS AND STUDY DESIGN: Popkin's framework was used to identify shifts in Nepalese diet and the inter-relationship of diet with epidemiological, demographic and economic shifts. The current study used quantitative methodology including secondary data analysis based on food balance sheets, economic surveys and the government databases. RESULTS: The Nepalese diet is shifting away from agricultural staple based foods to modern processed foods with higher total energy, total fat, and sugar. The prevalence of overweight/obesity and diet related non-communicable diseases are increasing. Urbanisation is rapid and nutrition transition already advanced in urban area. The Nepalese economic structure has also changed shifting away from agricultural food supply system towards modern processing based food supply system. These changes in the Nepalese diet are triggered by income and urbanisation. The trade liberalisation has made processed foods, edible oil and sugar easily available at supermarkets and fast food outlets. CONCLUSION: It is clear that Nepal has now entered into the fourth stage of nutrition transition according to Popkin's framework. As a result, overweight, obesity and the prevalence of many noncommunicable diseases are all rapidly growing. A further study is recommended to identify whether urban versus rural, rich versus poor and educated versus uneducated families are experiencing the transition in similar way.

The economic burden of HIV/AIDS on individuals and households in Nepal: a quantitative study.

BACKGROUND: There have been only limited studies assessing the economic burden of HIV/AIDS in terms of direct costs, and there has been no published study related to productivity costs in Nepal. Therefore, this study explores in detail the economic burden of HIV/AIDS, including direct costs and productivity costs. This paper focuses on the direct costs of seeking treatment, productivity costs, and related factors affecting direct costs, and productivity costs. METHODS: This study was a cross-sectional, quantitative study. The primary data were collected through a structured face-to-face survey from 415 people living with HIV/AIDS (PLHIV). The study was conducted in six representative treatment centres of six districts of Nepal. The data analysis regarding the economic burden (direct costs and productivity costs) was performed from the household's perspective. Descriptive statistics have been used, and regression analyses were applied to examine the extent, nature and determinants of the burden of the disease, and its correlations. RESULTS: Average total costs due to HIV/AIDS (the sum of average total direct and average productivity costs before adjustment for coping strategies) were Nepalese Rupees (NRs) 2233 per month (US$ 30.2/month), which was 28.5% of the sample households' average monthly income. The average total direct costs for seeking HIV/AIDS treatment were NRs 1512 (US$ 20.4), and average productivity costs (before adjustment for coping strategies) were NRs 721 (US$ 9.7). The average monthly productivity losses (before adjustment for coping strategies) were 5.05 days per person. The major determinants for the direct costs were household income, occupation, health status of respondents, respondents accompanied or not, and study district. Health status of respondents, ethnicity, sexual orientation and study district were important determinants for productivity costs. CONCLUSIONS: The study concluded that HIV/AIDS has caused a significant economic burden for PLHIV and their families in Nepal. The study has a number of policy implications for different stakeholders. Provision of social support and income generating programmes to HIV-affected individuals and their families, and decentralising treatment services in each district seem to be viable solutions to reduce the economic burden of HIV-affected individuals and households.

Economic Burden of HIV/AIDS Upon Households in Nepal: A Critical Review.

Thousands of people are infected with HIV/AIDS in Nepal and most of them are adults of working age. Therefore, HIV/AIDS is a big burden in Nepal. This review was conducted to find the existing knowledge gap about the economic burden of HIV/AIDS at the household level in Nepal, the extent of economic burden exerted by the disease, and to provide policy recommendations. It is concluded that there was a considerable knowledge gap about the issue, and the economic burden exerted by HIV/AIDS was big enough to push the affected households into poverty. It is suggested that more studies need to be conducted to fill the knowledge gap. Similarly, Government of Nepal and other organisations working in the field of HIV/AIDS need to provide economic supports (e.g.- support for travel costs) to the HIV positive people and need to increase the awareness level among general population for reducing stigma and discrimination, and reducing economic burden on them.

Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health.

BACKGROUND: The last decade has seen widespread retreat from user fees with the intention to reduce financial constraints to users in accessing health care and in particular improving access to reproductive, maternal and newborn health services. This has had important benefits in reducing financial barriers to access in a number of settings. If the policies work as intended, service utilization rates increase. However this increases workloads for health staff and at the same time, the loss of user fee revenues can imply that health workers lose bonuses or allowances, or that it becomes more difficult to ensure uninterrupted supplies of health care inputs.This research aimed to assess how policies reducing demand-side barriers to access to health care have affected service delivery with a particular focus on human resources for health. METHODS: We undertook case studies in five countries (Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe). In each we reviewed financing and HRH policies, considered the impact financing policy change had made on health service utilization rates, analysed the distribution of health staff and their actual and potential workloads, and compared remuneration terms in the public sectors. RESULTS: We question a number of common assumptions about the financing and human resource inter-relationships. The impact of fee removal on utilization levels is mostly not sustained or supported by all the evidence. Shortages of human resources for health at the national level are not universal; maldistribution within countries is the greater problem. Low salaries are not universal; most of the countries pay health workers well by national benchmarks. CONCLUSIONS: The interconnectedness between user fee policy and HRH situations proves difficult to assess. Many policies have been changing over the relevant period, some clearly and others possibly in response to problems identified associated with financing policy change. Other relevant variables have also changed.However, as is now well-recognised in the user fee literature, co-ordination of health financing and human resource policies is essential. This appears less well recognised in the human resources literature. This coordination involves considering user charges, resource availability at health facility level, health worker pay, terms and conditions, and recruitment in tandem. All these policies need to be effectively monitored in their processes as well as outcomes, but sufficient data are not collected for this purpose.

Productivity cost due to maternal ill health in Sri Lanka.

BACKGROUND: The global impact of maternal ill health on economic productivity is estimated to be over 15 billion USD per year. Global data on productivity cost associated with maternal ill health are limited to estimations based on secondary data. Purpose of our study was to determine the productivity cost due to maternal ill health during pregnancy in Sri Lanka. METHODS AND FINDINGS: We studied 466 pregnant women, aged 24 to 36 weeks, residing in Anuradhapura, Sri Lanka. A two stage cluster sampling procedure was used in a cross sectional design and all pregnant women were interviewed at clinic centers, using the culturally adapted Immpact tool kit for productivity cost assessment. Of the 466 pregnant women studied, 421 (90.3%) reported at least one ill health condition during the pregnancy period, and 353 (83.8%) of them had conditions affecting their daily life. Total incapacitation requiring another person to carry out all their routine activities was reported by 122 (26.1%) of the women. In this study sample, during the last episode of ill health, total number of days lost due to absenteeism was 3,356 (32.9% of total loss) and the days lost due to presenteeism was 6,832.8 (67.1% of the total loss). Of the 353 women with ill health conditions affecting their daily life, 280 (60%) had coping strategies to recover loss of productivity. Of the coping strategies used to recover productivity loss during maternal ill health, 76.8% (n = 215) was an intra-household adaptation, and 22.8% (n = 64) was through social networks. Loss of productivity was 28.9 days per episode of maternal ill health. The mean productivity cost due to last episode of ill health in this sample was Rs.8,444.26 (95% CI-Rs.6888.74-Rs.9999.78). CONCLUSIONS: Maternal ill health has a major impact on household productivity and economy. The major impact is due to, generally ignored minor ailments during pregnancy.

Applying the net-benefit framework for assessing cost-effectiveness of interventions towards universal health coverage.

In assessing the cost-effectiveness of an intervention, the interpretation and handling of uncertainties of the traditional summary measure, the Incremental Cost Effectiveness Ratio (ICER), can be problematic. This is particularly the case with strategies towards universal health coverage in which the decision makers are typically concerned with coverage and equity issues. We explored the feasibility and relative advantages of the net-benefit framework (NBF) (compared to the more traditional Incremental Cost-Effectiveness Ratio, ICER) in presenting results of cost-effectiveness analysis of a community based health insurance (CBHI) scheme in Nouna, a rural district of Burkina Faso. Data were collected from April to December 2007 from Nouna's longitudinal Demographic Surveillance System on utilization of health services, membership of the CBHI, covariates, and CBHI costs. The incremental cost of a 1 increase in utilization of health services by household members of the CBHI was 433,000 XOF ($1000 approximately). The incremental cost varies significantly by covariates. The probability of the CBHI achieving a 1% increase in utilization of health services, when the ceiling ratio is $1,000, is barely 30% for households in Nouna villages compared to 90% for households in Nouna town. Compared to the ICER, the NBF provides more useful information for policy making.

Applying the net-benefit framework for analyzing and presenting cost-effectiveness analysis of a maternal and newborn health intervention.

BACKGROUND: Coverage of maternal and newborn health (MNH) interventions is often influenced by important determinants and decision makers are often concerned with equity issues. The net-benefit framework developed and applied alongside clinical trials and in pharmacoeconomics offers the potential for exploring how cost-effectiveness of MNH interventions varies at the margin by important covariates as well as for handling uncertainties around the ICER estimate. AIM: We applied the net-benefit framework to analyze cost-effectiveness of the Skilled Care Initiative and assessed relative advantages over a standard computation of incremental cost effectiveness ratios. METHODS: Household and facility surveys were carried out from January to July 2006 in Ouargaye district (where the Skilled Care Initiative was implemented) and Diapaga (comparison site) district in Burkina Faso. Pregnancy-related and perinatal mortality were retrospectively assessed and data were collected on place of delivery, education, asset ownership, place, and distance to health facilities, costs borne by households for institutional delivery, and cost of standard provision of maternal care. Descriptive and regression analyses were performed. RESULTS: There was a 30% increase in institutional births in the intervention district compared to 10% increase in comparison district, and a significant reduction of perinatal mortality rates (OR 0.75, CI 0.70-0.80) in intervention district. The incremental cost for achieving one additional institutional delivery in Ouargaye district compared to Diapaga district was estimated to be 170 international dollars and varied significantly by covariates. However, the joint probability distribution (net-benefit framework) of the effectiveness measure (institutional delivery), the cost data and covariates indicated distance to health facilities as the single most important determinant of the cost-effectiveness analysis with implications for policy making. CONCLUSION: The net-benefit framework, the application of which requires household-level effects and cost data, has proven more insightful (than traditional ICER) in presenting and interpreting cost-effectiveness results of the Skilled Care Initiative.

A systematic review of economic evaluations of chemoprophylaxis for tuberculosis.

Since treatment of active disease remains the priority for tuberculosis control, donors and governments need to be convinced that investing resources in chemoprophylaxis provides health benefits and is good value for money. The limited evidence of cost effectiveness has often been presented in a fragmentary and inconsistent fashion. Objective. This review is aimed at critically reviewing the evidence of cost effectiveness of chemoprophylaxis against tuberculosis, identifying the important knowledge gaps and the current issues which confront policy makers. Methods. A systematic search on economic evaluations for chemoprophylaxis against tuberculosis was carried out, and the selected studies were checked for quality assessment against a standard checklist. Results. The review provides evidence of the cost effectiveness of chemoprophylaxis for all age groups which suggests that current policy should be amended to include a focus on older adults. Seven of the eight selected studies were undertaken wholly in high income countries but there are considerable doubts about the transferability of the findings of the selected studies to low and middle income countries which have the greatest incidence of latent tuberculosis infection. Conclusion. There is a pressing need to expand the evidence base to low and middle income countries where the vast majority of sufferers from tuberculosis live.

Willingness to pay for maternal health outcomes: are women willing to pay more than men?

BACKGROUND: Only a limited number of studies have specifically sought to analyse and try to understand sex differences in willingness to pay (WTP). OBJECTIVE: To identify the role of sex in determining monetary values placed upon improvements in maternal health in Burkina Faso, West Africa. METHODS: A contingent valuation survey using the bidding game method was conducted in the district of Nouna in 2005; a sample of 409 male heads of households and their spouses were asked their WTP for a reduction in the number of maternal deaths in the Nouna area. Ordinary least squares regression analysis was employed to examine the determinants of WTP. RESULTS: Men were willing to pay significantly more than women (3127 vs 2273 West African francs), although this represented a significantly smaller proportion of their annual income (4% vs 11%). In the multivariate analyses of all respondents there was a significant positive relationship between WTP values and both starting bid and whether there had been a previous maternal complication in the respondent's household. However, there was a significant negative relationship between WTP and female sex. Once interactions between sex and income were taken into account, income did affect valuations, with a positive relationship between higher-income women and WTP values. CONCLUSION: In absolute terms, men were willing to pay more than women, while women were willing to pay a greater proportion of their income. Differences between men and women in their WTP, both in absolute terms and in terms of proportion of income, can be explained by a household effect. Future studies should distinguish between individual income and command over decision making with respect to use of individual and household income, and gain further insight into the strategies used by respondents in answering bidding game questions.

A game of two halves? Incentive incompatibility, starting point bias and the bidding game contingent valuation method.

The bidding game (BG) method of contingent valuation is one way to increase the precision of willingness to pay (WTP) estimates relative to the single dichotomous choice approach. However, there is evidence that the method may lead to incentive incompatible responses and be associated with starting point bias. While previous studies in health using BGs test for starting point bias, none have also investigated incentive incompatibility. Using a sample of respondents resident in Burkina Faso, West Africa, this paper examines whether the BG method is associated with both incentive incompatibility and starting point bias. We find evidence for both effects. However, average WTP values remained largely unaffected after accounting for both factors in multivariate analyses. The results suggest that the BG method is an acceptable technique in settings where prices for goods are flexible.

Estimates of health care system costs of unsafe abortion in Africa and Latin America.

CONTEXT: Each year, 19 million unsafe abortions occur in developing countries, and an estimated five million women are treated for the resulting serious medical complications. Meanwhile, the economic impact of postabortion care on health care systems in Africa and Latin America is poorly understood (data for Asia are lacking). METHODS: Two main approaches were used to estimate the cost of postabortion care: calculating the average cost of care per patient, as represented in 20 empirical studies, and analyzing treatment costs using the WHO Mother-Baby Package model, which enumerates the costs of specific components of treatment related to postabortion complications. The average cost estimates from each approach were multiplied by the annual number of cases of hospitalization for postabortion care to generate regional cost estimates. Three methods (low severity, weighted severity, and inclusion of overhead and capital costs) were used to generate a range of per-patient and regional cost estimates. RESULTS: The average per-patient cost of postabortion care ranged from $83 in Africa to $94 in Latin America (2006 US$); estimates based on the WHO Mother-Baby Package model were between $57 and $109 per case. The health system costs of postabortion care in the two regions combined ranged from $159 million to $333 million per year. The average estimates from the two approaches were similar: $280 million and $274 million, respectively. CONCLUSIONS: The costs of treating medical complications from unsafe abortion constitute a significant financial burden on public health care systems in the developing world, and postabortion complications are a significant cause of maternal morbidity.

A cost-effectiveness study of caesarean-section deliveries by clinical officers, general practitioners and obstetricians in Burkina Faso.

BACKGROUND: The aim of this paper was to evaluate the effectiveness and cost-effectiveness of alternative training strategies for increasing access to emergency obstetric care in Burkina Faso. METHODS: Case extraction forms were used to record data on 2305 caesarean sections performed in 2004 and 2005 in hospitals in six out of the 13 health regions of Burkina Faso. Main effectiveness outcomes were mothers' and newborns' case fatality rates. The costs of performing caesarean sections were estimated from a health system perspective and Incremental Cost-Effectiveness Ratios were computed using the newborn case fatality rates. RESULTS: Overall, case mixes per provider were comparable. Newborn case fatality rates (per thousand) varied significantly among obstetricians, general practitioners and clinical officers, at 99, 125 and 198, respectively. The estimated average cost per averted newborn death (x1000 live births) for an obstetrician-led team compared to a general practitioner-led team was 11,757 international dollars, and for a general practitioner-led team compared to a clinical officer-led team it was 200 international dollars. Training of general practitioners appears therefore to be both effective and cost-effective in the short run. Clinical officers are associated with a high newborn case fatality rate. CONCLUSION: Training substitutes is a viable option to increase access to life-saving operations in district hospitals. The high newborn case fatality rate among clinical officers could be addressed by a refresher course and closer supervision. These findings may assist in addressing supply shortages of skilled health personnel in sub-Saharan Africa.

Assessing the costs and cost-effectiveness of a skilled care initiative in rural Burkina Faso.

OBJECTIVES: The objectives of this study were to assess the cost-effectiveness of a skilled attendance strategy (the Skilled Care Initiative, SCI) in enhancing maternal health care in a remote, rural district of Burkina Faso and to analyse more broadly the costs and cost patterns of maternal health provision in the intervention and comparison districts. METHODS: The approach used was to cost the standard provision of maternal care, to analyse the main cost structures, and to derive cost estimates per facility. The additional costs attributable to SCI were identified. Several measures of cost-effectiveness or performance were calculated, including cost per delivery and utilisation. RESULTS: If the increase in deliveries in Ouargaye between 2004 and 2005 is attributed solely to the stimulus of demand for skilled care by the SCI community mobilisation and behavioural communication change activities, the incremental cost per delivery was $164 international dollars. This compares with an average cost per delivery in Health Centres across the two districts of $214 international dollars. However, if a broader measure of SCI costs is used, the incremental cost per delivery increases markedly, to $1306 international dollars. At the level of individual Health Centres, utilisation is a better measure of performance than cost per delivery and Health Centres in Ouargaye are utilised more than in Diapaga. CONCLUSIONS: Demand side actions, such as community mobilisation and behavioural communication change activities, can be as important in improving skilled care at delivery as investment in health facilities, assuming there is some spare capacity, as has been the case in Burkina Faso. These conclusions have important potential implications for planning and resource allocation to achieve safer delivery for all women in Burkina Faso.

Costing universal access of highly active antiretroviral therapy in Benin.

The study aimed to estimate costs of provision and access to highly active antiretroviral therapy (HAART) in order to assist in planning and resource allocation regarding scaling up and sustainable access to HAART in Benin. A prospective study was carried out to collect data on costs of provision of care at the Outpatient Treatment Centre (OTC) of the National University hospital in Cotonou, Benin and on costs borne by people living with HIV/AIDS (PLWHA) and their families in accessing care. We used an Excel model, a macro costing approach and WHO guidelines for costing health services. Annual costs were subsequently extrapolated from a societal perspective over a 10-year time horizon. Sensitivity analysis was conducted on major cost categories. The study population was mostly of middle age (median age of 38, IQR 34-42), married (65%), working class (60%) with low literacy (70% primary education level or less). The main drivers of costs of HAART service provision were drugs (73%), biological monitoring (15%) and personnel (8%). Annual costs of provision of HAART and household costs borne by PLWHA and families in seeking care amounted to 1160 USD and 111 USD per PLWHA respectively. These household costs are respectively 40% and 14% of household health and education related costs and may represent catastrophic health expenditures for patients and families. The provision of drugs and biological monitoring, and household costs in accessing care, remain by far the main barriers to ensuring universal access to HAART.