The cost of universal free access for treating HIV/AIDS in low-income countries: the case of Senegal

Since late 2003 in Senegal, voluntary tests, ARVs and CD4 counts have been provided free of charge by the State within the framework of public health services. Debate now focuses on expanding free access to other components of care (consultations, hospitalizations, complementary exams for opportunistic infections). A preliminary study assessed the supplementary cost needed to fund all care and appraised this measure's impact on the national program. Direct costs for treatment were calculated using two different methods: (1) by calculating total expenditures for a sample of 299 patients over a 22-month period (July 2003 to April 2005) treated by HAART (2 NRTI + 1 PI or NNRTI); and (2) by assessing the theoretical costs necessary to apply the national treatment protocols. Furthermore, national budgetary projections were analyzed to estimate possible margins available to officials. In 2006, the total cost of medical care for someone taking ARVs falls around 412€ per year; 84% of the cost covers the price of ARVs and reagents for CD4 counts. The total annual cost of medical care for a PLWHA who does not need ARV drugs is approximately 40€ per year, with 90% of this amount covering biological exams. Projections concerning changes in the number of PLWHA and treatment needs and analysis of budget estimations for 2007-2011 demonstrate that supplementary costs incurred by complete free access could be easily covered without disrupting the proposed funding plan. Complete free access for medical care for all PLWHA in the country is therefore economically feasible; what remains is to define this decision's integration into the current paying health system without causing disturbances that render the decision ineffective.VIH ; sida ; mdicaments antirétroviraux ; prise en charge médicale ; accès aux soins ; financement de la santé ; gratuité ; payement par les usagers ; Sénégal

Implementing funding modalities for free access: The case for a "purchasing fund system" to cover medical care

The principle of free access to ARVs was recognized in Senegal in 2003. Debate now focuses on its expansion to cover all therapeutic care (consultations, exams, treatment for opportunistic infections). Expenditures incurred by this complementary packet often impede access to care. The main difficulty does not really arise from the need for funding but rather from how this treatment is managed and its impact on the current financing systems. In fact, four types of possible funding exist: (1) provision in kind of products necessary for the consumption of free services; (2) providing equipment that allows other revenues in compensation for losses created by free access; (3) increased public budgetary grants; (4) reimbursement for services by a third party. In this last solution, the third party may be the State or an ad hoc organism (NGO, insurance, designated fund). The study compares these different modalities across specific conditions in Senegal and describes their possible impact on the present and future health system. In effect, this analysis fits into a much broader debate since the principle of free access has already expanded to other domains, particularly childbirth (2003) and care for the elderly (2006). The study shows that the multiplication of parallel supplies, the coexistence of various “free” stocks and insufficient accounting of services might create serious disturbances in current management and financing systems. On the other hand, invoice reimbursements set up in some districts by various partners preserve financial autonomy and strengthen the managerial capacities of health structures. Nevertheless, with the increased number of people who are treated and the expansion of free access to other services, there is a risk of letting the number of individual mechanisms multiply when common services would be more effective. Given the financial limitations of community financing schemes and the difficulties to develop insurance systems in a very informal economy, it is now necessary to envisage the implementation of “purchasing funds,” for which the study proposes basic guidelines. Based on the logic of insurance, they rely on purchasing a predetermined service package (contractualization and accreditation), using the sectoral approach (by “pooling” public, private and international resources), funding based on results (a payment for services rendered) and management that is independent of public budgetary blockages (with the participation of civil society). Complete medical treatment for PLWHA may be the best way to progressively start this process because the service package is clearly predetermined, its cost has been assessed and the number of beneficiaries, in a country like Senegal, is still low. Moreover, if proper management of this fund can be ensured, institutional sustainability will ensure its financial sustainability. Therefore the fight against HIV/AIDS could contribute to reflection on health system reform.VIH ; sida ; accès aux soins ; financement de la santé ; fonds d'achat ; gratuité ; Sénégal

Distribution of nest preparation tasks between mates of the Redbilled Hornbill Tockus erythrorhynchus

Le Petit Calao à bec rouge, #Tockus erythrorhynchus$, bien qu'abondant et largement réparti dans une grande partie de l'Afrique sub-saharienne, est encore mal connu du point de vue systématique et éthologique. Pendant la période de reproduction les tâches sont bien réparties entre conjoints. Nous avons effectué au Sénégal 80 heures d'observation pendant les deux principales étapes de l'aménagement du nid : apport de matériaux et fermeture partielle de l'entrée du nid. Durant la première étape de préparation du nid, le mâle a passé plus de temps à l'inspection du nid, au toilettage et à son nourrissage ; la femelle a apporté plus de matériaux au nid. A la seconde étape de préparation, la femelle a fermé presque seule l'entrée du nid et s'est reposée moins que le mâle. Il revient au mâle de choisir le site de reproduction et de défendre le nid. Le choix des matériaux pour tapisser l'intérieur du nid et le colmatage de l'entrée avec de la boue sont dévolus presque entièrement à la femelle. Quelques jours avant sa claustration, la femelle ouvre et referme l'entrée du nid une fois de l'extérieur, une autre de l'intérieur pour entrer ou sortir. (Résumé d'auteur

The cost of universal free access for treating HIV/AIDS in low-income countries: the case of Senegal

Since late 2003 in Senegal, voluntary tests, ARVs and CD4 counts have been provided free of charge by the State within the framework of public health services. Debate now focuses on expanding free access to other components of care (consultations, hospitalizations, complementary exams for opportunistic infections). A preliminary study assessed the supplementary cost needed to fund all care and appraised this measure's impact on the national program. Direct costs for treatment were calculated using two different methods: (1) by calculating total expenditures for a sample of 299 patients over a 22-month period (July 2003 to April 2005) treated by HAART (2 NRTI + 1 PI or NNRTI); and (2) by assessing the theoretical costs necessary to apply the national treatment protocols. Furthermore, national budgetary projections were analyzed to estimate possible margins available to officials. In 2006, the total cost of medical care for someone taking ARVs falls around 412€ per year; 84% of the cost covers the price of ARVs and reagents for CD4 counts. The total annual cost of medical care for a PLWHA who does not need ARV drugs is approximately 40€ per year, with 90% of this amount covering biological exams. Projections concerning changes in the number of PLWHA and treatment needs and analysis of budget estimations for 2007-2011 demonstrate that supplementary costs incurred by complete free access could be easily covered without disrupting the proposed funding plan. Complete free access for medical care for all PLWHA in the country is therefore economically feasible; what remains is to define this decision's integration into the current paying health system without causing disturbances that render the decision ineffective

Implementing funding modalities for free access: The case for a "purchasing fund system" to cover medical care

The principle of free access to ARVs was recognized in Senegal in 2003. Debate now focuses on its expansion to cover all therapeutic care (consultations, exams, treatment for opportunistic infections). Expenditures incurred by this complementary packet often impede access to care. The main difficulty does not really arise from the need for funding but rather from how this treatment is managed and its impact on the current financing systems. In fact, four types of possible funding exist: (1) provision in kind of products necessary for the consumption of free services; (2) providing equipment that allows other revenues in compensation for losses created by free access; (3) increased public budgetary grants; (4) reimbursement for services by a third party. In this last solution, the third party may be the State or an ad hoc organism (NGO, insurance, designated fund). The study compares these different modalities across specific conditions in Senegal and describes their possible impact on the present and future health system. In effect, this analysis fits into a much broader debate since the principle of free access has already expanded to other domains, particularly childbirth (2003) and care for the elderly (2006). The study shows that the multiplication of parallel supplies, the coexistence of various “free” stocks and insufficient accounting of services might create serious disturbances in current management and financing systems. On the other hand, invoice reimbursements set up in some districts by various partners preserve financial autonomy and strengthen the managerial capacities of health structures. Nevertheless, with the increased number of people who are treated and the expansion of free access to other services, there is a risk of letting the number of individual mechanisms multiply when common services would be more effective. Given the financial limitations of community financing schemes and the difficulties to develop insurance systems in a very informal economy, it is now necessary to envisage the implementation of “purchasing funds,” for which the study proposes basic guidelines. Based on the logic of insurance, they rely on purchasing a predetermined service package (contractualization and accreditation), using the sectoral approach (by “pooling” public, private and international resources), funding based on results (a payment for services rendered) and management that is independent of public budgetary blockages (with the participation of civil society). Complete medical treatment for PLWHA may be the best way to progressively start this process because the service package is clearly predetermined, its cost has been assessed and the number of beneficiaries, in a country like Senegal, is still low. Moreover, if proper management of this fund can be ensured, institutional sustainability will ensure its financial sustainability. Therefore the fight against HIV/AIDS could contribute to reflection on health system reform

(Cy2NH2O2CPh)3(SnCl4)2 AND (SnBu2)4(O2CPh)16Cl6(OH)2(Cy2NH2)16: SYNTHESIS AND SPECTROSCOPIC CHARACTERIZATION

The two title compounds have been synthesized, their IR and Mössbauer studies carried out. The structures are discrete and contain mono- and bidentate PhCO2-, the environment around the tin (IV) centre being octahedral (in SnCl4 adduct), trapezoidal bipyramidal (in the SnBu2 residue containing derivative). A tetranuclear monomeric or an oligomeric structure is suggested in the tetranuclear SnBu2 residue containing derivative