Search

Abstract Introduction The poorest in Burkina Faso face numerous barriers to healthcare access, including financial and geographic obstacles, as well as a high burden of chronic conditions and multimorbidity. This study estimates the average cost of providing curative outpatient consultations at first-level healthcare facilities to the poorest in Burkina Faso. It also estimates the budgetary impact of scaling up free access to these services nationwide. The findings provide essential evidence on cost structures to inform decision-makers in developing policies aimed at achieving universal health coverage and ensuring that no one is left behind. Methods We conducted a micro-costing study to estimate the economic costs of providing curative outpatient healthcare services to the poorest at first-level healthcare facilities, considering a health system perspective. We measured the consumption of capital costs (building and equipment) using survey data from 32 primary health facilities and recurrent costs (drugs and consumables) from medical records of 1380 poor patients in Diébougou district. These individuals were targeted and exempted from user fees through a community-based targeting approach. We obtained unit costs from official price lists, pharmacy registries, and expert interviews. We calculated the national budget for providing curative care services to the exempted poorest based on the average cost per first-level consultation. Results The estimated capital and recurrent costs of providing curative care services ranged between USD 0.59 - USD 0.61 and USD 2.58 - USD 5.00, respectively. The total cost ranged between USD 3.17 - USD 5.61 per first-level consultation. Providing curative care to the bottom 20% of the population, assuming 0.25 healthcare contacts per person per year, would result in an annual expense ranging from USD 2.77 M to USD 5.38 M (0.74-1.43% of the healthcare budget in 2019). With 2 healthcare contacts per person per year, costs increase to USD 22.19 M to USD 43.05 M (5.91-11.45% of the healthcare budget). Conclusion The results can inform policies aimed at expanding access to curative care for the poorest in Burkina Faso, contributing to the goals of universal health coverage and leaving no one behind. Further research is needed to enhance cost estimation and budgeting for higher-level care in the country.

Abstract Background Since climate change, pandemics and population mobility are challenging healthcare systems, an empirical and integrative research to studying and help improving the health systems resilience is needed. We present an interdisciplinary and mixed-methods research protocol, ClimHB, focusing on vulnerable localities in Bangladesh and Haiti, two countries highly sensitive to global changes. We develop a protocol studying the resilience of the healthcare system at multiple levels in the context of climate change and variability, population mobility and the Covid-19 pandemic, both from an institutional and community perspective. Methods The conceptual framework designed is based on a combination of Levesque’s Health Access Framework and the Foreign, Commonwealth and Development Office’s Resilience Framework to address both outputs and the processes of resilience of healthcare systems. It uses a mixed-method sequential exploratory research design combining multi-sites and longitudinal approaches. Forty clusters spread over four sites will be studied to understand the importance of context, involving more than 40 healthcare service providers and 2000 households to be surveyed. We will collect primary data through questionnaires, in-depth and semi-structured interviews, focus groups and participatory filming. We will also use secondary data on environmental events sensitive to climate change and potential health risks, healthcare providers’ functioning and organisation. Statistical analyses will include event-history analyses, development of composite indices, multilevel modelling and spatial analyses. Discussion This research will generate inter-disciplinary evidence and thus, through knowledge transfer activities, contribute to research on low and middle-income countries (LMIC) health systems and global changes and will better inform decision-makers and populations.

Introduction: The poorest in Burkina Faso face numerous barriers to healthcare access, including financial and geographic obstacles, as well as a high burden of chronic conditions and multimorbidity. This study estimates the average cost of providing curative outpatient consultations at first-level healthcare facilities to the poorest in Burkina Faso. It also estimates the budgetary impact of scaling up free access to these services nationwide. The findings provide essential evidence on cost structures to inform decision-makers in developing policies aimed at achieving universal health coverage and ensuring that no one is left behind. Methods: We conducted a micro-costing study to estimate the economic costs of providing curative outpatient healthcare services to the poorest at first-level healthcare facilities, considering a health system perspective. We measured the consumption of capital costs (building and equipment) using survey data from 32 primary health facilities and recurrent costs (drugs and consumables) from medical records of 1380 poor patients in Diébougou district. These individuals were targeted and exempted from user fees through a community-based targeting approach. We obtained unit costs from official price lists, pharmacy registries, and expert interviews. We calculated the national budget for providing curative care services to the exempted poorest based on the average cost per first-level consultation. Results: The estimated capital and recurrent costs of providing curative care services ranged between USD 0.59 - USD 0.61 and USD 2.58 - USD 5.00, respectively. The total cost ranged between USD 3.17 - USD 5.61 per first-level consultation. Providing curative care to the bottom 20% of the population, assuming 0.25 healthcare contacts per person per year, would result in an annual expense ranging from USD 2.77 M to USD 5.38 M (0.74-1.43% of the healthcare budget in 2019). With 2 healthcare contacts per person per year, costs increase to USD 22.19 M to USD 43.05 M (5.91-11.45% of the healthcare budget). Conclusion: The results can inform policies aimed at expanding access to curative care for the poorest in Burkina Faso, contributing to the goals of universal health coverage and leaving no one behind. Further research is needed to enhance cost estimation and budgeting for higher-level care in the country. [ABSTRACT FROM AUTHOR]

Abstract Background The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. Methods This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. Discussion We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention’s impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. Trial registration Registered with RIDIE (RIDIE-STUDY-ID-54412a964bce8) on 10/17/2014.

Abstract Background Results-based financing (RBF) describes health system approaches addressing both service quality and use. Effective coverage is a metric measuring progress towards universal health coverage (UHC). Although considered a means towards achieving UHC in settings with weak health financing modalities, the impact of RBF on effective coverage has not been explicitly studied. Methods Malawi introduced the Results-Based Financing For Maternal and Neonatal Health (RBF4MNH) Initiative in 2013 to improve quality of maternal and newborn health services at emergency obstetric care facilities. Using a quasi-experimental design, we examined the impact of the RBF4MNH on both crude and effective coverage of pregnant women across four districts during the two years following implementation. Results There was no effect on crude coverage. With a larger proportion of women in intervention areas receiving more effective care over time, the overall net increase in effective coverage was 7.1%-points (p = 0.07). The strongest impact on effective coverage (31.0%-point increase, p = 0.02) occurred only at lower cut-off level (60% of maximum score) of obstetric care effectiveness. Design-specific and wider health system factors likely limited the program’s potential to produce stronger effects. Conclusion The RBF4MNH improved effective coverage of pregnant women and seems to be a promising reform approach towards reaching UHC. Given the short study period, the full potential of the current RBF scheme has likely not yet been reached.

Abstract Background In 2013, Malawi with its development partners introduced a Results-Based Financing for Maternal and Newborn Health (RBF4MNH) intervention to improve the quality of maternal and newborn health-care services. Financial incentives are awarded to health facilities conditional on their performance and to women for delivering in the health facility. We assessed the effect of the RBF4MNH on quality of care from women’s perspectives. Methods We used a mixed-method prospective sequential controlled pre- and post-test design. We conducted 3060 structured client exit interviews, 36 in-depth interviews and 29 focus group discussions (FGDs) with women and 24 in-depth interviews with health service providers between 2013 and 2015. We used difference-in-differences regression models to measure the effect of the RBF4MNH on experiences and perceived quality of care. We used qualitative data to explore the matter more in depth. Results We did not observe a statistically significant effect of the intervention on women’s perceptions of technical care, quality of amenities and interpersonal relations. However, in the qualitative interviews, most women reported improved health service provision as a result of the intervention. RBF4MNH increased the proportion of women reporting to have received medications/treatment during childbirth. Participants in interviews expressed that drugs, equipment and supplies were readily available due to the RBF4MNH. However, women also reported instances of neglect, disrespect and verbal abuse during the process of care. Providers attributed these negative instances to an increased workload resulting from an increased number of women seeking services at RBF4MNH facilities. Conclusion Our qualitative findings suggest improvements in the availability of drugs and supplies due to RBF4MNH. Despite the intervention, challenges in the provision of quality care persisted, especially with regard to interpersonal relations. RBF interventions may need to consider including indicators that specifically target the provision of respectful maternity care as a means to foster providers’ positive attitudes towards women in labour. In parallel, governments should consider enhancing staff and infrastructural capacity before implementing RBF.

Abstract Background Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection. Methods The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004–06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004–2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models. Results We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase. Conclusions Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it’s essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations.

Background: Evidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi.Methods: The study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households.Results: A total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs.Conclusion: Our study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs. [ABSTRACT FROM AUTHOR]