Scaling up family planning in Zambia—Part 2: The cost of scaling up family planning services

This costing study is Part 2 of a broader implementation research study designed to establish the feasibility of integrating successful interventions and lessons from the Scaling Up Family Planning (SUFP) project into Zambia’s health system at the conclusion of the project, and to contribute to the global learning on scaling up family planning services. The main contribution of the costing study was to examine the cost implications in determining the scope and pace of scale up. Challenges experienced during the project reportedly included lack of equipment and limited space in some facilities, government staff shortages, and irregular access to supplies of oral contraceptives and condoms at the community level. Sustainability of interventions after the end of the project was a major concern, with doubts over the ability of the government to cover the costs of outreach, supply chain, and community-based distribution (CBD) support costs that have been covered by the project. Finally, finding solutions to high CBD attrition rates was identified as a key challenge. The report details lessons learned from this project and makes recommendations, including further research that would be beneficial both for the country and globally

Seasonal malaria chemoprevention in the Sahel subregion of Africa: a cost-effectiveness and cost-savings analysis.

BACKGROUND: The intermittent administration of seasonal malaria chemoprevention (SMC) is recommended to prevent malaria among children aged 3-59 months in areas of the Sahel subregion in Africa. However, the cost-effectiveness and cost savings of SMC have not previously been evaluated in large-scale studies. METHODS: We did a cost-effectiveness and cost-savings analysis of a large-scale, multi-country SMC campaign with sulfadoxine-pyrimethamine plus amodiaquine for children younger than 5 years in seven countries in the Sahel subregion (Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria, and The Gambia) in 2016. The financial and economic costs were analysed from the programmatic perspective and are reported in 2016 US$for each country. The estimated numbers of averted malaria cases, deaths, and disability-adjusted life-years (DALYs) were based on numbers of SMC treatments administered and modelled malaria transmission. Cost savings were calculated from a programmatic perspective corresponding to the diagnostic and treatment costs for malaria cases averted. FINDINGS: The total cost of SMC for all seven countries was$22·8 million, and the weighted average economic cost of administering four monthly SMC cycles was $3·63 per child (ranging from$2·71 in Niger to $8·20 in The Gambia). Based on 80$2·91 in Niger to $30·73 in The Gambia; the cost per severe case averted ranged from$119·63 in Niger to $506·00 in The Gambia; the cost per death averted ranged from$533·56 in Niger to $2256·92 in The Gambia; and the cost per DALY averted (discounted by 3$18·66 in Niger to $78·91 in The Gambia. The estimated total economic cost savings to the health systems in all seven countries were US$66·0 million and the total net economic cost savings were US$43·2 million. INTERPRETATION: SMC is a low-cost and highly cost-effective intervention that contributes to substantial cost savings by reducing malaria diagnostic and treatment costs among children. FUNDING: Unitaid

An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria

IntroductionThe availability of quality primary health care (PHC) services in Nigeria is limited. The PHC system faces significant challenges and the improvement and expansion of PHC services is constrained by low government spending on health, especially on PHC. Out-of-pocket (OOP) expenditures dominate health spending in Nigeria and the reliance on OOP payments leads to financial burdens on the poorest and most vulnerable populations. To address these challenges, the Nigerian government has implemented several legislative and policy reforms, including the National Health Insurance Authority (NHIA) Act enacted in 2022 to make health insurance mandatory for all Nigerian citizens and residents. Our study aimed to determine the costs of providing PHC services at public health facilities in Kaduna and Kano, Nigeria. We compared the actual PHC service delivery costs to the normative costs of delivering the Minimum Service Package (MSP) in the two states.MethodsWe collected primary data from 50 health facilities (25 per state), including PHC facilities—health posts, health clinics, health centers—and general hospitals. Data on facility-level recurrent costs were collected retrospectively for 2019 to estimate economic costs from the provider’s perspective. Statewide actual costs were estimated by extrapolating the PHC cost estimates at sampled health facilities, while normative costs were derived using standard treatment protocols (STPs) and the populations requiring PHC services in each state.ResultsWe found that average actual PHC costs per capita at PHC facilities—where most PHC services should be provided according to government guidelines—ranged from US$18.9 to US$ 28 in Kaduna and US$15.9 to US$ 20.4 in Kano, depending on the estimation methods used. When also considering the costs of PHC services provided at general hospitals—where approximately a third of PHC services are delivered in both states—the actual per capita costs of PHC services ranged from US$20 to US$ 30.6 in Kaduna and US$17.8 to US$ 22 in Kano. All estimates of actual PHC costs per capita were markedly lower than the normative per capita costs of delivering quality PHC services to all those who need them, projected at US$44.9 in Kaduna and US$ 49.5 in Kano.DiscussionBridging this resource gap would require significant increases in expenditures on PHC in both states. These results can provide useful information for ongoing discussions on the implementation of the NHIA Act including the refinement of provider payment strategies to ensure that PHC providers are remunerated fairly and that they are incentivized to provide quality PHC services

Costs and resource needs for primary health care in Ethiopia: evidence to inform planning and budgeting for universal health coverage

IntroductionThe Government of Ethiopia (GoE) has made significant progress in expanding access to primary health care (PHC) over the past 15 years. However, achieving national PHC targets for universal health coverage will require a significant increase in PHC financing. The purpose of this study was to generate cost evidence and provide recommendations to improve PHC efficiency.MethodsWe used the open access Primary Health Care Costing, Analysis, and Planning (PHC-CAP) Tool to estimate actual and normative recurrent PHC costs in nine Ethiopian regions. The findings on actual costs were based on primary data collected in 2018/19 from a sample of 20 health posts, 25 health centers, and eight primary hospitals. Three different extrapolation methods were used to estimate actual costs in the nine sampled regions. Normative costs were calculated based on standard treatment protocols (STPs), the population in need of the PHC services included in the Essential Health Services Package (EHSP) as per the targets outlined in the Health Sector Transformation Plan II (HSTP II), and the associated costs. PHC resource gaps were estimated by comparing actual cost estimates to normative costs.ResultsOn average, the total cost of PHC in the sampled facilities was US$11,532 (range: US$ 934–40,746) in health posts, US$254,340 (range: US$ 68,860–832,647) in health centers, and US$634,354 (range: US$ 505,208–970,720) in primary hospitals. The average actual PHC cost per capita in the nine sampled regions was US$4.7, US$ 15.0, or US$20.2 depending on the estimation method used. When compared to the normative cost of US$ 38.5 per capita, all these estimates of actual PHC expenditures were significantly lower, indicating a shortfall in the funding required to deliver an expanded package of high-quality services to a larger population in line with GoE targets.DiscussionThe study findings underscore the need for increased mobilization of PHC resources and identify opportunities to improve the efficiency of PHC services to meet the GoE’s PHC targets. The data from this study can be a critical input for ongoing PHC financing reforms undertaken by the GoE including transitioning woreda-level planning from input-based to program-based budgeting, revising community-based health insurance (CBHI) packages, reviewing exempted services, and implementing strategic purchasing approaches such as capitation and performance-based financing

Sharing knowledge for policy action in low- and middle-income countries: A literature review of managed entry agreements

Managed entry agreements (MEAs)—a type of formal institutional arrangement between pharmaceutical companies and payers for sharing the risk with respect to the introduction of new pharmaceutical technologies—may expand access to new pharmaceutical technologies for non-communicable diseases (NCDs). Although common in highincome countries (HICs), there is limited evidence of their use in low- and middle-income countries (LMICs). This article aims to document international experiences of countries implementing MEAs and potential barriers and facilitators for their use in LMICs. We reviewed published literature sources on MEAs over the past 10 years considering peer-reviewed publications and gray literature data. We took into consideration the MEAs taxonomy presented by Kanavos and Ferrario et al. to categorize our findings, and extract information on factors for their implementation. We retrieved 285 MEAs documented in the literature, mostly from HICs and for a broad spectrum of NCDs. Financial schemes were slightly more prominent than performance-based agreements. Identified factors that could potentially facilitate or hinder the implementation of MEAs included the presence of quality administrative and information systems to track their implementation; availability of quality data and evidence of positive outcomes; uncertainty of drug efficacy/effectiveness, safety, and financial impact; and cultural factors, namely country’s preference for certain type of agreement and trust among payers and manufacturers. The increased availability of publications in recent years suggests a growing interest among policy-makers and researchers in the implementation of MEAs. While the use of MEAs in LMICs is very limited, this could be the result of limited empirical evidence on its use and possibly due to the use of a different taxonomy for describing MEAs in these settings. As any other policy option, the implementation and use of MEAs come with advantages and challenges. Since there is limited evidence on their use in LMICs, the identified cases of implementation in HICs may serve to inform the interest on MEAs in resource limited settings. Therefore, further research in this field especially in the context of LMICs may be of value for the global community as all countries are embarking into fairer and sustainable Universal Health Coverage (UHC)

Table_1_An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria.docx

IntroductionThe availability of quality primary health care (PHC) services in Nigeria is limited. The PHC system faces significant challenges and the improvement and expansion of PHC services is constrained by low government spending on health, especially on PHC. Out-of-pocket (OOP) expenditures dominate health spending in Nigeria and the reliance on OOP payments leads to financial burdens on the poorest and most vulnerable populations. To address these challenges, the Nigerian government has implemented several legislative and policy reforms, including the National Health Insurance Authority (NHIA) Act enacted in 2022 to make health insurance mandatory for all Nigerian citizens and residents. Our study aimed to determine the costs of providing PHC services at public health facilities in Kaduna and Kano, Nigeria. We compared the actual PHC service delivery costs to the normative costs of delivering the Minimum Service Package (MSP) in the two states.MethodsWe collected primary data from 50 health facilities (25 per state), including PHC facilities—health posts, health clinics, health centers—and general hospitals. Data on facility-level recurrent costs were collected retrospectively for 2019 to estimate economic costs from the provider’s perspective. Statewide actual costs were estimated by extrapolating the PHC cost estimates at sampled health facilities, while normative costs were derived using standard treatment protocols (STPs) and the populations requiring PHC services in each state.ResultsWe found that average actual PHC costs per capita at PHC facilities—where most PHC services should be provided according to government guidelines—ranged from US$18.9 to US$ 28 in Kaduna and US$15.9 to US$ 20.4 in Kano, depending on the estimation methods used. When also considering the costs of PHC services provided at general hospitals—where approximately a third of PHC services are delivered in both states—the actual per capita costs of PHC services ranged from US$20 to US$ 30.6 in Kaduna and US$17.8 to US$ 22 in Kano. All estimates of actual PHC costs per capita were markedly lower than the normative per capita costs of delivering quality PHC services to all those who need them, projected at US$44.9 in Kaduna and US$ 49.5 in Kano.DiscussionBridging this resource gap would require significant increases in expenditures on PHC in both states. These results can provide useful information for ongoing discussions on the implementation of the NHIA Act including the refinement of provider payment strategies to ensure that PHC providers are remunerated fairly and that they are incentivized to provide quality PHC services.</p

Table_1_The costs and financing needs of delivering Kenya’s primary health care service package.docx

IntroductionFor many Kenyans, high-quality primary health care (PHC) services remain unavailable, inaccessible, or unaffordable. To address these challenges, the Government of Kenya has committed to strengthening the country’s PHC system by introducing a comprehensive package of PHC services and promoting the efficient use of existing resources through its primary care network approach. Our study estimated the costs of delivering PHC services in public sector facilities in seven sub-counties, comparing actual costs to normative costs of delivering Kenya’s PHC package and determining the corresponding financial resource gap to achieving universal coverage.MethodsWe collected primary data from a sample of 71 facilities, including dispensaries, health centers, and sub-county hospitals. Data on facility-level recurrent costs were collected retrospectively for 1 year (2018–2019) to estimate economic costs from the public sector perspective. Total actual costs from the sampled facilities were extrapolated using service utilization data from the Kenya Health Information System for the universe of facilities to obtain sub-county and national PHC cost estimates. Normative costs were estimated based on standard treatment protocols and the populations in need of PHC in each sub-county.Results and discussionThe average actual PHC cost per capita ranged from US$9.3 in Ganze sub-county to US$ 47.2 in Mukurweini while the normative cost per capita ranged from US$31.8 in Ganze to US$ 42.4 in Kibwezi West. With the exception of Mukurweini (where there was no financial resource gap), closing the resource gap would require significant increases in PHC expenditures and/or improvements to increase the efficiency of PHC service delivery such as improved staff distribution, increased demand for services and patient loads per clinical staff, and reduced bypass to higher level facilities. This study offers valuable evidence on sub-national cost variations and resource requirements to guide the implementation of the government’s PHC reforms and resource mobilization efforts.</p