Health Policy and Planning - current issue

Global health funding: how much, where it comes from and where it goes

McCoy, D., Chand, S., Sridhar, D. — Tue, 20 Oct 2009 23:25:58 PDT

Global health funding has increased in recent years. This has been accompanied by a proliferation in the number of global health actors and initiatives. This paper describes the state of global heath finance, taking into account government and private sources of finance, and raises and discusses a number of policy issues related to global health governance. A schematic describing the different actors and three global health finance functions is used to organize the data presented, most of which are secondary data from the published literature and annual reports of relevant actors. In two cases, we also refer to currently unpublished primary data that have been collected by authors of this paper. Among the findings are that the volume of official development assistance for health is frequently inflated; and that data on private sources of global health finance are inadequate but indicate a large and important role of private actors. The fragmented, complicated, messy and inadequately tracked state of global health finance requires immediate attention. In particular it is necessary to track and monitor global health finance that is channelled by and through private sources, and to critically examine who benefits from the rise in global health spending.

The value of hygiene promotion: cost-effectiveness analysis of interventions in developing countries

Sijbesma, C., Christoffers, T. — Tue, 20 Oct 2009 23:25:58 PDT

Hygiene promotion can greatly improve the benefits of water and sanitation programmes in developing countries at relatively limited costs. There are, however, few studies with hard data on the costs and effectiveness of individual programmes and even fewer have compared the cost-effectiveness of different promotional approaches. This article argues that objectively measured reductions of key sanitation and hygiene risks are better than DALYs for evaluating hygiene and sanitation promotion programmes. It presents a framework for the cost-effectiveness analysis of such programmes, which is used to analyse six field programmes. At costs ranging from US$1.05 to US$1.74 per person per year in 1999 US$ values, they achieved (almost) complete abandonment of open defecation and considerable improvements in keeping toilets free from faecal soiling, safe disposal of child faeces, and/or washing hands with soap after defecation, before eating and after cleaning children's bottoms. However, only two studies used a quasi-experimental design (before and after studies in the intervention and – matched – control area) and only two measured costs and the degree to which results were sustained after the programme had ended. If the promotion of good sanitation and hygiene is to receive the political and managerial support it deserves, every water, sanitation and/or hygiene programme should give data on inputs, costs, processes and effects over time. More and better research that reflects the here-presented model is also needed to compare the cost-effectiveness of different promotional approaches.

Knowledge and practices for preventing severe malaria in Yemen: the importance of gender in planning policy

al-Taiar, A., Chandler, C., Al Eryani, S., Whitty, C. J M — Tue, 20 Oct 2009 23:25:58 PDT

Objective In Yemen, morbidity and mortality due to malaria is high. We explored malaria-related treatment seeking, prevention practices and knowledge of transmission amongst parents in order to inform health education strategies. Yemen is culturally very distinct from most malaria-endemic countries. We aimed to identify beliefs which may be barriers to malaria prevention and treatment, and hypothesized that household gender relationships might impact on practice.

Methods Focus group discussions amongst women and men in urban, semi-urban and rural areas, followed by questionnaire interviews with parents or guardians of children with severe malaria, mild malaria, and healthy children from the community.

Findings Recognition of malarial symptoms was good but delays in seeking medical treatment after symptom onset were common, with 78% of parents reporting delay. Delays primarily related to financial constraints, but also to difficulties with treatment seeking when male family members were not available. When contact with a health worker occurred prior to admission to the hospital, the treatment was potentially inappropriate in 29% and ineffective in 57%. There were distinct differences between men and women in their perspective on malaria. Knowledge of malaria transmission was vague and mosquitoes were not emphasized, particularly amongst mothers. Bednets were reported to be used rarely and without insecticide treatment, and some beliefs such as that malaria is transmitted by breastfeeding were potentially harmful.

Conclusions Some beliefs were potential barriers to malaria prevention strategies. The different beliefs and roles identified between men and women need to be taken into account in health promotion messages.

Cost-effectiveness analysis of active management of third-stage labour in Vietnam

Tsu, V. D, Levin, C., Tran, M. P T, Hoang, M. V, Luu, H. T T — Tue, 20 Oct 2009 23:25:58 PDT

Active management of the third stage of labour (AMTSL) using oxytocin substantially reduces postpartum haemorrhage (PPH), a leading cause of maternal mortality. An economic analysis of the use of AMTSL was conducted as part of an intervention study in Thanh Hoa Province, Vietnam. A spreadsheet was used to calculate various scenarios and estimate the costs and outcomes of the routine use of AMTSL with oxytocin in Uniject compared with oxytocin in ampoules, and AMTSL compared with no AMTSL. We estimated the health outcomes from probabilities that were generated from the effectiveness portion of the AMTSL intervention project. The study also estimates the costs of treating PPH and the net incremental costs of AMTSL (costs and savings); examines the impact of different scenarios of PPH rate and Uniject cost; and estimates the potential cost per PPH case and PPH death averted.

The additional net cost per woman of providing AMTSL with ampoules was just US$0.20 in the base case; using Uniject devices added only US$0.08 more per woman to the ampoule cost. Varying the rate of PPH had the biggest effect; if the underlying PPH rate were 8%, the incremental cost of AMTSL drops to just US$0.07 per woman with ampoules and the cost to avert a case of PPH is US$2.10 with ampoules and US$4.52 with Uniject. The low net incremental cost of AMTSL suggests that the introduction of AMTSL in primary-level facilities in Vietnam can reduce the incidence of PPH and benefit women's health without adding much to national health care costs.

Incidence and correlates of 'catastrophic' maternal health care expenditure in India

Bonu, S., Bhushan, I., Rani, M., Anderson, I. — Tue, 20 Oct 2009 23:25:58 PDT

Using data from the 60^th round of the National Sample Survey of India (2004), the study investigates the incidence and correlates of ‘catastrophic’ maternal expenditure (ME) in India. Data on ME come from 6879 births that took place during 365 days prior to the survey. The study adapts earlier definitions and methods for catastrophic total health care expenditure to measure ‘catastrophic’ ME as: (i) maternal health care expenditure more than 10% of the annual normative household consumption expenditure (ME-1), and (ii) maternal health care expenditure more than 40% of the annual ‘capacity to pay’ (ME-2). The ‘capacity to pay’ was derived by subtracting state-wise poverty-line household expenditure from household consumption expenditure.

The average maternal expenditure varied by place of delivery: US$9.5, US$24.7 and US$104.3 for birth at home, in a public facility and in a private facility, respectively. Sixteen per cent of households incurred ME of more than 10% of total household consumption expenditure (ME-1), while 51% households incurred ME of more than 40% of household ‘capacity to pay’ (ME-2). While incidence of ME-1 increased with income decile, the reverse was observed for ME-2, reflecting higher non-utilization of institutional maternal care and its non-affordability among poorer households. All the households from the poorest decile and 99% from the second poorest decile paid more than 40% of their capacity to pay. Multivariate regression results indicate that antenatal care and delivery care in private facilities increased the chances of ME-1 and ME-2 (P < 0.001).

Measuring maternal expenditure against ‘capacity to pay’ (ME-2) may be better than measuring it as a proportion of overall household expenditure when assessing financial constraints in the use of maternal services. Improving the performance of the public sector, appropriate regulation of and partnership with the private sector, and effective direct cash transfers to pregnant women in the poorest households may increase utilization of maternal services and reduce the financial distress associated with ME.

Quality of tuberculosis care and its association with patient adherence to treatment in eight Ethiopian districts

Tue, 20 Oct 2009 23:25:58 PDT

Background Little is known about the quality of tuberculosis (TB) service delivery in public health facilities in Ethiopia and its association with patients’ non-adherence to TB treatment. This study assessed the organization, management and processes of TB care delivery, and their effects on patients’ adherence to TB treatment.

Methods The quality of TB care was investigated in 44 public health facilities from three perspectives: structure, processes of TB care delivery and patient treatment outcome. Quality of care was determined by adherence to national TB guidelines. On-site observations of TB service delivery and interviews with health providers were conducted to evaluate structural factors. Patients (n = 237) in the health facilities were interviewed prospectively at completion of their treatment to determine the quality of tuberculosis care delivered. Three measures of treatment adherence [treatment interruption (≥2 weeks), availability of unused TB drugs and treatment default] were quantified from a review of patient treatment registers and an audit of unused TB drugs at patients’ homes. Effects were identified of poor quality structures and processes of service delivery on these three measures of adherence.

Results TB care providers were untrained in 18 (44%) of 44 facilities and daily outpatient TB care was not given in 13 of 44 (25%). Among the 237 patients, 43% interrupted treatment for ≥15 days and 30% had at least 1 day's dose of TB drugs unused. Patients tended to interrupt and default from treatment when their care provider had been inadequately supervised by district TB control experts and was incapable of dealing with patients’ minor illnesses. Unavailability of daily TB care in health facilities was associated with missing daily doses.

Conclusion Better training of TB care providers and district supervisory support could be important interventions to improve the quality of care delivery and patient adherence to treatment.

Informal sector providers in Bangladesh: how equipped are they to provide rational health care?

Ahmed, S. M., Hossain, Md. A., Chowdhury, M. R. — Tue, 20 Oct 2009 23:25:58 PDT

In Bangladesh, there is a lack of knowledge about the large body of informal sector practitioners, who are the major providers of health care to the poor, especially in rural areas, knowledge which is essential for designing a need-based, pro-poor health system. This paper addresses this gap by presenting descriptive data on their professional background including knowledge and practices on common illnesses and conditions from a nationwide, population-based health-care provider survey undertaken in 2007. The traditional healers (43%), traditional birth attendants (TBAs, 22%), and unqualified allopathic providers (village doctors and drug sellers, 16%) emerged as major providers in the health care scenario of Bangladesh. Community health workers (CHWs) comprised about 7% of the providers. The TBAs/traditional healers had <5 years of schooling on average compared with 10 years for the others. The TBAs/traditional healers were professionally more experienced (average 18 years) than the unqualified allopaths (average 12 years) and CHWs (average 8 years). Their main routes of entry into the profession were apprenticeship and inheritance (traditional healers, TBAs, drug sellers), and short training (village doctors) of few weeks to a few months from semi-formal, unregulated private institutions. Their professional knowledge base was not at a level necessary for providing basic curative services with minimum acceptable quality of care. The CHWs trained by the NGOs (46%) were relatively better in the rational use of drugs (e.g. use of antibiotics) than the unqualified allopathic providers. It is essential that the public sector, instead of ignoring, recognize the importance of the informal providers for the health care of the poor. Consequently, their capacity should be developed through training, supportive supervision and regulatory measures so as to accommodate them in the mainstream health system until constraints on the supply of qualified and motivated health care providers into the system can be alleviated.

10 best resources on ... health workers in developing countries

Grepin, K. A, Savedoff, W. D — Tue, 20 Oct 2009 23:25:58 PDT

Estimating inequalities in ownership of insecticide treated nets: does the choice of socio-economic status measure matter?

Chuma, J., Molyneux, C. — Tue, 20 Oct 2009 23:25:58 PDT