Cost-effectiveness analysis of insecticide-impregnated mosquito nets (bednets) used as a malaria control measure : a study from the Gambia.

Insecticide-impregnated bednets are currently being promoted as one of the promising malaria control methods in endemic regions of most developing countries. Although, much is known about the entomological and epidemiological aspects of treated bednets, little is known about the efficiency of malaria control programmes in general, and bednets in particular. This cost-effectiveness analysis forms part of the evaluation of the Gambian National Insecticide-impregnated Bednet Programme (NIBP). The research was conducted in the rural Gambia where malaria is endemic. An integrated approach to data collection approach (qualitative and quantitative) provided information for the four objectives of the study, namely; 1. to calculate the total NIBP implementation costs (ie' direct and indirect costs); 2. to estimate the number of child (under 10 years) deaths averted in the intervention area; 3. to calculate the resources saved by averting a child death to the health sector and households both direct (ie saved treatment costs, saved preventive expenditures, postponed funeral expenses) and indirect (ie time costs saved by carers and relatives that can be spent on productive activities) and subtract these from the programme costs, to produce net cost-effectiveness ratios and 4. to investigate the effect of impregnated bednets on primary school attendance in terms of days and reasons for absenteeism. The study covered 64 government and non-governmental organization personnel, 179 village dippers, 306 women in groups of 5 8 in focus group discussions, 25 in-depth interviews of men, 134 carers of children, 50 women in random spot observations and 2182 pupils in school attendance study. The main findings of the study were; 1. The annual implementation cost of NIBP was D757,874.72. 2. The implementation and the net cost-effectiveness ratios per child death averted were D4,946.63 and D1,332.31 respectively and, 3 . Impregnated bednets were observed to reduce absenteeism due to ill-health. NIBP was an efficient malaria control method in rural Gambia and saved resources

Socio-economic Differentials in Health Care Seeking Behaviour and Out-Of-Pocket expenditure for OPD Services in Madina Township

The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003 in an effort to address issues of inequities in financial access to health care. The aim of this study was to determine the trends of health care seeking behaviour by socio-economic status (SES) and out-of-pocket expenditure of OPD visits in Madina Township in Ghana. A population-based, cross-sectional household survey was carried out in Madina Township in the Ga-East Municipal, Accra, Ghana, using structured questionnaires to obtain information from a random sample of 378 household heads using a two-week recall period. The study found NHIS enrolment levels in Madina Township to be far below expectations (27.5%). There were disparities in waiting times indicating higher delays of insured patients. Despite the financial protection that the NHIS offers, poor households continue to incur significant costs on health care services. In addition, household perceptions regarding not only costs but also quality of service, severity of illness and proximity were found to influence choice of health services. Household SES continues to exert influence on choice of health services despite the introduction of NHIS. Efforts to improve enrolment and health service utilization must take cognizance of the broader range of factors that may challenge or even erode gains, if just the costs of health care are addressed as an isolated item. Key Words: OPD visit, insured, non-insured, out-of-pocket expenditure, socio-economic status, Ghana

Fragmentation of care during pregnancy in the Volta Region of Ghana: A social network analysis approach

To determine the extent of care fragmentation during pregnancy and delivery in the Volta Region of Ghana. The National Health Insurance Claims Data for the Volta Region for the period January –December 2013 was used. Pregnant women who delivered at a health facility and made at least 3 visits were included in the study. Social network analysis (SNA) approach was used to determine care fragmentation. Fragmentation of care during delivery was defined to be any delivery at a facility different from the woman’s most frequently visited antenatal care (ANC) facility. Network metrics (weighted in-degree and weighted out-degree) were used to determine extent of care fragmentation and also the key facilities contributing to the fragmentation. Overall, 14,474 pregnant women were included in the study with 15% (2,185) having cesarean section (CS). A total of 6,025 (42%) of all the pregnant women visited more than one facility during ANC and delivery, out of which 960 (16%) had CS. About 26% (3,769) of all deliveries and 32% (696) of all CS deliveries were fragmented. Fragmentation among those that had CS was significantly higher compared to those that had vaginal delivery (VD) (32% versus 25%, 2=45.88, p<0.001). Among those who visited multiple facilities, 63% (73% CS and 61% VD, 2=49.22, p<0.001) were fragmented. In addition, 15% of all deliveries (36% among those who visited multiple facilities) and 20% of all CS deliveries (45% among those who visited multiple facilities) were performed at facilities that the pregnant women never received ANC services from. There is high level of care fragmentation during the critical period of delivery among pregnant women who visited more than one facility. This fragmentation is particularly higher among those that had CS compared to vaginal delivery. This calls for policy to ensure coordination and continuity of care during pregnancy

Extent of Integration of Priority Interventions into General Health Systems: A Case Study of Neglected Tropical Diseases Programme in the Western Region of Ghana

Background The global health system has a large arsenal of interventions, medical products and technologies to address current global health challenges. However, identifying the most effective and efficient strategies to deliver these resources to where they are most needed has been a challenge. Targeted and integrated interventions have been the main delivery strategies. However, the health system discourse increasingly favours integrated strategies in the context of functionally merging targeted interventions with multifunctional health care delivery systems with a focus on strengthening country health systems to deliver needed interventions. Neglected Tropical Diseases (NTD) have been identified to promote and perpetuate poverty hence there has been global effort to combat these diseases. The Neglected Tropical Diseases Programme (NTDP) in Ghana has a national programme team and office, however, it depends on the multifunctional health delivery system at the regional and district level to implement interventions. The NTDP seeks further health system integration to accelerate achievement of coverage targets. The study estimated the extent of integration of the NTDP at the national, regional and district levels to provide evidence to guide further integration. Methodology/Principal Findings The research design was a descriptive case study that interviewed key persons involved in the programme at the three levels of the health system as well as extensive document review. Integration was assessed on two planes—across health system functions–stewardship and governance, financing, planning, service delivery, monitoring and evaluation and demand generation; and across three administrative levels of the health system–national, regional and district. A composite measure of integration designated Cumulative Integration Index (CII) with a range of 0.00–1.00 was used to estimate extent of integration at the three levels of the health system. Service delivery was most integrated while financing and planning were least integrated. Extent of integration was partial at all levels of the health system with a CII of 0.48–0.68; however it was higher at the district compared to the national and regional levels. Conclusions/Significance To ensure further integration of the NTDP, planning and finance management activities must be decentralized to involve regional and district levels of the health system. The study provides an empirical measure of extent of integration and indicators to guide further integration. Author Summary Two main strategies have been used to address diseases that affects large sections of populations. One strategy called targeted or vertical programme sets up separate system from the general health system with its own human resources, management, implementation, data reporting and evaluation systems. Integrated (also called horizontal) strategy on the other hand uses existing health system structures to implement activities to control target health problems. Integrated strategy is preferred because it strengthens country health systems. The Neglected Tropical Diseases Programme (NTDP) in Ghana has a dedicated management structure at the national level but uses general health system structures at the regional and district levels to implement activities. This study assessed the extent of integration of the NTDP into the health system at the national, regional and district levels. It was found that the NTDP activities were better integrated at the district compared to the regional and national levels of the health system. Furthermore, it also found that service delivery activities were most integrated while financing and planning activities were least integrated at all levels of the health system. These findings provide points to guide efforts to make the NTDP more integrated and can be applied to other health programmes

Financial stress spillover across Asian Countries.

This paper uses fractional integration techniques to explore the stochastic properties of the Financial Stress Indices (FSIs) of 10 Asian countries, further investigating the bilateral linkages between them to ascertain how financial stress spreads among countries in the region. For the FSIs of each country, the results show that all the estimated orders of integration are in the interval (0, 1) implying fractional integration and a long memory pattern. Thus, shocks will have transitory though long‐lasting effects. For the cross‐country spillovers of the FSIs, we find that convergence is satisfied in all cases with values of the differencing parameter around 0 and thus showing short memory behavior. It is worth noting that for the larger economies in the region, Japan and China, financial stress transmission between Japan and the smaller economies was faster than with respect to China. Overall, the results provide valuable information on the financial market activity of the countries in the region. To check for the robustness of the baseline results we also use systemic risk measures for these countries, CoVaR with the results showing evidence of fractional integration for the individual series, with all values of the differencing parameter in the range (0, 1). For convergence, there is a substantial reduction in the degree of integration, though the results are not as clear as with the FSIs.pre-print412 K

Managerial capacity among district health managers and its association with district performance: a comparative descriptive study of six districts in the Eastern Region of Ghana

District health managers play a pivotal role in the delivery of basic health services in many countries, including Ghana, as they are responsible for converting inputs and resources such as, staff, supplies and equipment into effective services that are responsive to population needs. Weak management capacity among local health managers has been suggested as a major obstacle for responsive health service delivery. However, evidence on district health managers' competencies and its association with health system performance is scarce.; To examine managerial capacity among district health managers and its association with health system performance in six districts in the Eastern Region of Ghana.; Fifty-nine district health managers' in six different performing districts in the Eastern Region of Ghana completed a self-administered questionnaire measuring their management competencies and skills. In addition, the participants provided information on their socio-demographic background; previous management experience and training; the extent of available management support systems, and the dynamics within their district health management teams. A non-parametric one-way analysis was applied to test the association between management capacity and district performance, which was measured by 17 health indicators.; Shortcomings within different aspects of district management were identified, however there were no significant differences observed in the availability of support systems, characteristics and qualifications of district health managers across the different performing districts. Overall management capacity among district health managers were significantly higher in high performing districts compared with lower performing districts (p = 0.02). Furthermore, district health managers in better performing districts reported a higher extent of teamwork (p = 0.02), communication within their teams (p<0.01) and organizational commitment (p<0.01) compared with lower performing districts.; The findings demonstrate individual and institutional capacity needs, and highlights the importance of developing management competencies and skills as well as positive team dynamics among health managers at district level

Malaria Treatment in Northern Ghana: What is the Treatment Cost per Case to Households?

Although malaria is a major problem in Sub-Saharan African countries including Ghana, there has been little research on its economic impact, particularly the treatment cost at the household level. This study uses data collected from a random sample of 423 households in Kassena-Nankana district (KND) of northern Ghana. Malaria was ascertained through self-reporting of symptoms using a one-month recall period. The paper presents treatment cost analysis of seeking malaria care to households. Direct and indirect costs to households are estimated and examined in terms of location, severity, and wealth. The study shows that indirect cost accounts for 71 percent of total cost of a malaria episode. While cost of malaria care is estimated at 1 percent of the income of the rich, it is 34 percent of the poor households\u2019 income, suggesting that the burden of malaria is higher for poorer households. In order to reduce the cost of malaria to households, we recommend that the training of malaria volunteers to assist households in the communities to take more responsibility of the disease and also to intensify public education to promote the use of insecticide treated nets, as they have been found to be cost-effective in the prevention of malaria

Determinants of health insurance enrolment in Ghana: evidence from three national household surveys

In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) to move towards Universal Health Coverage. NHIS enrolment is mandatory for all Ghanaians, but the most recent estimates show that coverage stands under 40%. The evidence on the relationship between socio-economic characteristics and NHIS enrolment is mixed, and comes mainly from studies conducted in a few areas. Therefore, in this study we investigate the socio-economic determinants of NHIS enrolment using three recent national household surveys. We used data from the Ghanaian Demographic and Health Survey conducted in 2014, the Multiple Indicator Cluster Survey conducted in 2011 and the sixth wave of the Ghana Living Standard Survey conducted in 2012-13. Given the multilevel nature of the three databases, we use multilevel logistic regression models to estimate the probability of enrolment for women and men separately. We used three levels of analysis: geographical clusters, household and individual units. We found that education, wealth, marital status-and to some extent-age were positively associated with enrolment. Furthermore, we found that enrolment was correlated with the type of occupation. The analyses of three national household surveys highlight the challenges of understanding the complex dynamics of factors contributing to low NHIS enrolment rates. The results indicate that current policies aimed at identifying and subsidizing underprivileged population groups might insufficiently encourage health insurance enrolment

How does district health management emerge within a complex health system? Insights for capacity strengthening in Ghana

Introduction:; District health managers (DHMs) play a pivotal role in the operation of district health systems in low-and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system in which they are embedded. The objective of this paper is to explore how district health management emerges from contextual, organizational, and individual factors in order to demonstrate that capacity strengthening efforts at district level need to transcend individual competencies to take on more systemic approaches.; Methods:; Semi-structured interviews (; n; = 21) were conducted to gain insight into aspects that affect district health management in the Eastern Region of Ghana. Interviews were conducted with DHMs (; n; = 15) from six different districts, as well as with their superiors at the regional level (; n; = 4) and peers from non-governmental organizations (; n; = 2). A thematic analysis was conducted by using an analytical approach based on systems theory.; Results:; Contextual aspects, such as priorities among elected officials, poor infrastructure and working conditions, centralized decision-making, delayed disbursement of funds and staff shortages, affect organizational processes and the way DHMs carry out their role. Enabling organizational aspects that provide DHMs with direction and a clear perception of their role, include positive team dynamics, good relations with supervisors, job descriptions, appraisals, information systems, policies and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by vertical programs and limited opportunities for professional development provide DHMs with limited authority to make decisions and dampens their motivation. The DHMs ability to carry out their role effectively depends on their perception of their role and the effort they expend, in addition to their competencies. In regards to competencies, a need for more general management and leadership skills were called for by DHMs as well as by their superiors and peers.; Conclusion:; Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management