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The impact of market concentration has been little studied in markets for ambulatory care in the developing world, where the retail sector often accounts for a high proportion of treatments. This study begins to address this gap through an analysis of the consumer market for malaria treatment in rural areas of three districts in Tanzania. We developed methods for investigating market definition, sales volumes and concentration, and used these to explore the relationship between antimalarial retail prices and competition.The market was strongly geographically segmented and highly concentrated in terms of antimalarial sales. Antimalarial prices were positively associated with market concentration. High antimalarial prices were likely to be an important factor in the low proportion of care-seekers obtaining appropriate treatment.Retail sector distribution of subsidised antimalarials has been proposed to increase the coverage of effective treatment, but this analysis indicates that local market power may prevent such subsidies from being passed on to rural customers. Policymakers should consider the potential to maintain lower retail prices by decreasing concentration among antimalarial providers and recommending retail price levels.

This article examines the existence of price discrimination for obstetric services in two private hospitals in Bangladesh, and considers the welfare consequences of such discrimination, i.e. whether or not price discrimination benefited the poorer users. Data on 1212 normal and caesarean section patients discharged from the two hospitals were obtained. Obstetric services were chosen because they are relatively standardised and the patient population is relatively homogeneous, so minimising the scope and scale of product differentiation due to procedure and case-mix differences. The differences between the hospital list price for delivery and actual prices paid by patients were calculated to determine the average rate of discount. The welfare consequences of price discrimination were assessed by testing the differences in mean prices paid by patients from three income groups: low, middle and high. The results suggest that two different forms of price discrimination for obstetric services occurred in both these hospitals. First, there was price discrimination according to income, with the poorer users benefiting from a higher discount rate than richer ones; and second, there was price discrimination according to social status, with three high status occupational groups (doctors, senior government officials, and large businessmen) having the highest probability of receiving some level of discount.

Access to effective treatment would substantially reduce the burden of malaria in sub-Saharan Africa, but resistance to chloroquine, the most commonly used first line drug, is now widespread. There has been considerable debate over the level of chloroquine resistance at which a new first line drug should be adopted. Two issues make this an extremely complex decision: it involves trade-offs in costs and health outcomes over time; and many of the parameters are uncertain. A modelling approach was identified as appropriate for addressing these issues. The costs and effects of changing from chloroquine to sulphadoxine-pyrimethamine (SP) as the first line drug were modelled over 10 years, allowing for growth in drug resistance. Probabilistic sensitivity analysis was used to allow for the high levels of parameter uncertainty. The optimal year of switch was highly dependent on both empirical values, such as initial resistance and resistance growth rates, and on subjective values, such as the time preferences of policy-makers. It was not possible to provide policy-makers with a definitive threshold resistance level at which to switch, but the model can be used as an analytical tool to structure the problem, explore trade-offs, and identify areas for which data are lacking.

Contracts have played a central role in public sector reforms in developed countries over the last decade, and research increasingly highlights their varied nature. In low and middle income countries the use of contracts is encouraged but little attention has been paid to features of the setting that may influence their operation. A qualitative case study was used to examine different dimensions of a contract with private GPs in South Africa. Features of the contract are compared with the notions of classical and relational contracts. Formal aspects of the contract such as design, monitoring and resort to sanctions were found to offer little control over its outcome. The relational rather than classical model of contracting offered a more meaningful framework of analysis, with social and institutional factors found to play an important role. In particular, the individual nature of GP practices highlighted the role played by individual motivation where a contract exercised little formal control. Due to the similarity of factors likely to be present, results are argued to be relevant in many other LMIC settings, and policy-makers considering contracts for clinical services are advised to consider the possibility of experiencing a similar outcome.

The research reported here assessed the value of malaria control through a cost-effectiveness study of the vertically-organized malaria control programme in Nepal. It presents a methodological framework for analysing cost-effectiveness which includes resource-saving consequences as well as health consequences. The methods used to collect data on control costs, cases and deaths prevented, treatment costs averted and production gains are described and the assumptions required by the analysis are made explicit. A variety of cost-effectiveness ratios are calculated, sensitivity analysis applied and the policy implications of the results considered. The results from Nepal are compared to estimates for parasitic disease and other health programmes in other countries: it is concluded that the Nepalese programme appears no less cost-effective than many other health interventions. It can also be justified by reference to the population groups benefiting from malaria control.