Impact of health financing policies in Cambodia: a 20 year experience

Improving financial access to services is an essential part of extending universal health coverage in low resource settings. In Cambodia, high out of pocket spending and low levels of utilisation have impeded the expansion of coverage and improvement in health outcomes. For twenty years a series of health financing policies have focused on mitigating costs to increase access particularly by vulnerable groups. Demand side financing policies including health equity funds, vouchers and community health insurance have been complemented by supply side measures to improve service delivery incentives through contracting. Multiple rounds of the Cambodia Socio-Economic Survey are used to investigate the impact of financing policies on health service utilisation and out of pocket payments both over time using commune panel data from 1997 to 2011 and across groups using individual data from 2004 to 2009. Policy combinations including areas with multiple interventions were examined against controls using difference-in-difference and panel estimation. Widespread roll-out of financing policies combined with user charge formalisation has led to a general reduction in health spending by the poor. Equity funds are associated with a reduction in out of pocket payments although the effect of donor schemes is larger than those financed by government. Vouchers, which are aimed only at reproductive health services, has a more modest impact that is enhanced when combined with other schemes. At the aggregate level changes are less pronounced although there is evidence that policies take a number of years to have substantial effect. Health financing policies and the supportive systems that they require provide a foundation for more radical extension of coverage already envisaged by a proposed social insurance system. A policy challenge is how disparate mechanisms can be integrated to ensure that vulnerable groups remain protected

Free health care for under-fives, expectant and recent mothers? Evaluating the impact of Sierra Leone's free health care initiative.

This study evaluates the impact of Sierra Leone's 2010 Free Health Care Initiative (FHCI). It uses two nationally representative surveys to identify the impact of the policy on utilisation of maternal care services by pregnant women and recent mothers as well as the impact on curative health care services and out-of-pocket payments for consultation and prescription in children under the age of 5 years. A Regression Discontinuity Design (RDD) is applied in the case of young children and a before-after estimation approach, adjusted for time trends in the case of expectant and recent mothers. Our results suggest that children affected by the FHCI have a lower probability of incurring any health expenditure in public, non-governmental and missionary health facilities. However, a proportion of eligible children are observed to incur some health expenditure in participating facilities with no impact of the policy on the level of out-of-pocket health expenditure. Similarly, no impact is observed with the utilisation of services in these facilities. Utilisation of informal care is observed to be higher among non-eligible children while in expectant and recent mothers, we find substantial but possibly transient increases in the use of key maternal health care services in public facilities following the implementation of the FHCI. The diminishing impact on utilisation mirrors experience in other countries that have implemented free health care initiatives and demonstrates the need for greater domestic and international efforts to ensure that resources are sufficient to meet increasing demand and monitor the long run impact of these policies

Projecting the fiscal impact of South Africa’s contraceptive needs: Scaling up family planning post 2020

Background. Evidence-informed priority setting is vital to improved investment in public health interventions. This is particularly important as South Africa (SA) makes the shift to universal health coverage and institution of National Health Insurance.Objectives. To measure the financial impact of increasing the demand for modern contraceptive methods in the SA public health sector. We estimated the total cost of providing contraceptives, and specifically the budgetary impact of premature removals of long-acting reversible contraceptives.Methods. We created a deterministic model in Microsoft Excel to estimate the costs of contraception provision over a 5-year time horizon (2018 - 2023) from a healthcare provider perspective. Only direct costs of service provision were considered, including drugs, supplies and personnel time. Costs were not discounted owing to the short time horizon. Scenario analyses were conducted to test uncertainty.Results. The base-case cost of current contraceptive use in 2018 was estimated to be ZAR1.64 billion (ZAR29 per capita). Injectable contraceptives accounted for ~47% of total costs. To meet the total demand for family planning, SA would have to spend ~30% more than the estimate for current contraceptive use. In the year 2023, the ‘current use’ of modern contraceptives would increase to ZAR2.2 billion, and fulfilling the total demand for family planning would require ZAR2.9 billion. The base-case cost of implantable contraceptives was estimated at ZAR54 million. Assuming a normal removal rate, the use of implants is projected to increase by 20% during the 5-year period between 2019 and 2023, with an estimated 46% increase in costs. The cost of early removal of Implanon NXT is estimated at ZAR75 million, with total contraception costs estimated at ZAR102 million in 2019, compared with ZAR56 million when a normal removal rate is applied.Conclusions. The costs of scaling up modern contraceptives in SA are substantial. Early and premature removals of implantable contraceptives are costly to the nation and must be minimised. The government should consider conducting appropriate health technology assessments to inform the introduction of new public health interventions as SA makes the shift to universal health coverage by means of National Health Insurance.

Changes in catastrophic health expenditure in post-conflict Sierra Leone: an Oaxaca-blinder decomposition analysis.

BACKGROUND: At the end of the eleven-year conflict in Sierra Leone, a wide range of policies were implemented to address both demand- and supply-side constraints within the healthcare system, which had collapsed during the conflict. This study examines the extent to which households' exposure to financial risks associated with seeking healthcare evolved in post-conflict Sierra Leone. METHOD: This study uses the 2003 and 2011 cross-sections of the Sierra Leone Integrated Household Survey to examine changes in catastrophic health expenditure between 2003 and 2011. An Oaxaca-Blinder decomposition approach is used to quantify the extent to which changes in catastrophic health expenditure are attributable to changes in the distribution of determinants (distributional effect) and to changes in the impact of these determinants on the probability of incurring catastrophic health expenditure (coefficient effect). RESULTS: The incidence of catastrophic health expenditure decreased significantly by 18% from approximately 50% in 2003 t0 32% in 2011. The decomposition analysis shows that this decrease represents net effects attributable to the distributional and coefficient effects of three determinants of catastrophic health expenditure - ill-health, the region in which households reside and the type of health facility used. A decrease in the incidence of ill-health and changes in the regional location of households contributed to a decrease in catastrophic health expenditure. The distributional effect of health facility types observed as an increase in the use of public health facilities, and a decrease in the use of services in facilities owned by non-governmental organizations (NGOs) also contributed to a decrease in the incidence of catastrophic health expenditure. However, the coefficient effect of public health facilities and NGO-owned facilities suggests that substantial exposure to financial risk remained for households utilizing both types of health facilities in 2011. CONCLUSION: The findings support the need to continue expanding current demand-side policies in Sierra Leone to reduce the financial risk of exposure to ill health

Could a Shigella vaccine impact long-term health outcomes?: Summary report of an expert meeting to inform a Shigella vaccine public health value proposition, March 24 and 29, 2021.

Shigellosis is a leading cause of diarrhea and dysentery in young children from low to middle-income countries and adults experiencing traveler's diarrhea worldwide. In addition to acute illness, infection by Shigella bacteria is associated with stunted growth among children, which has been linked to detrimental long-term health, developmental, and economic outcomes. On March 24 and 29, 2021, PATH convened an expert panel to discuss the potential impact of Shigella vaccines on these long-term outcomes. Based on current empirical evidence, this discussion focused on whether Shigella vaccines could potentially alleviate the long-term burden associated with Shigella infections. Also, the experts provided recommendations about how to best model the burden, health and vaccine impact, and economic consequences of Shigella infections. This international multidisciplinary panel included 13 scientists, physicians, and economists from multiple relevant specialties. According to the panel, while the relationship between Shigella infections and childhood growth deficits is complex, this relationship likely exists. Vaccine probe studies are the crucial next step to determine whether vaccination could ameliorate Shigella infection-related long-term impacts. Infants should be vaccinated during their first year of life to maximize their protection from severe acute health outcomes and ideally reduce stunting risk and subsequent negative long-term developmental and health impacts. With vaccine schedule crowding, targeted or combination vaccination approaches would likely increase vaccine uptake in high-burden areas. Shigella impact and economic assessment models should include a wider range of linear growth outcomes. Also, these models should produce a spectrum of results-ones addressing immediate benefits for usual health care decision-makers and others that include broader health impacts, providing a more comprehensive picture of vaccination benefits. While many of the underlying mechanisms of this relationship need better characterization, the remaining gaps can be best addressed by collecting data post-vaccine introduction or through large trials

Cost-Effectiveness of Docetaxel and Paclitaxel for Adjuvant Treatment of Early Breast Cancer: Adaptation of a Model-Based Economic Evaluation From the United Kingdom to South Africa

Objectives Transferability of economic evaluations to low- and middle-income countries through adaptation of models is important; however, several methodological and practical challenges remain. Given its significant costs and the quality-of-life burden to patients, adjuvant treatment of early breast cancer was identified as a priority intervention by the South African National Department of Health. This study assessed the cost-effectiveness of docetaxel and paclitaxel-containing chemotherapy regimens (taxanes) compared with standard (non-taxane) treatments. Methods A cost-utility analysis was undertaken based on a UK 6-health-state Markov model adapted for South Africa using the Mullins checklist. The analysis assumed a 35-year time horizon. The model was populated with clinical effectiveness data (hazard ratios, recurrence rates, and adverse events) using direct comparisons from clinical trials. Resource use patterns and unit costs for estimating cost parameters (drugs, diagnostics, consumables, personnel) were obtained from South Africa. Uncertainty was assessed using probabilistic and deterministic sensitivity analyses. Results The incremental cost per patient for the docetaxel regimen compared with standard treatment was R6774. The incremental quality-adjusted life years (QALYs) were 0.24, generating an incremental cost-effectiveness ratio of R28430 per QALY. The cost of the paclitaxel regimen compared with standard treatment was estimated as −R578 and −R1512, producing an additional 0.03 and 0.025 QALYs, based on 2 trials. Paclitaxel, therefore, appears to be a dominant intervention. The base case results were robust to all sensitivity analyses. Conclusions Based on the adapted model, docetaxel and paclitaxel are predicted to be cost-effective as adjuvant treatment for early breast cancer in South Africa

Parental Income and Smoking Participation in Adolescents: Implications of misclassification error in empirical studies of adolescent smoking participation

In adults, the negative relationship between smoking and income is well established. However divergent results have been reported on the impact of parental socioeconomic status on adolescent smoking. In this study we investigate the extent to which misclassification errors in self-reported smoking affects estimates of the impact of parental income on smoking in adolescents aged 11-15 years old. We use the Household Survey for England (HSE) which contains both a self-reported smoking component and an objective measure of smoking obtained through cotinine assays. Smoking participation is modelled using self-reported smoking and cotinine-validated smoking as binary dependent variables in two separate probit models. We compare marginal effects of parental income (and other independent variables) in both models. Our results suggest that self-reported smoking is misreported leading to biased estimates of the effect of parental income on adolescent smoking. Income-related inequality in smoking (the concentration index) is also underestimated when misclassification errors vary across income quintiles.Adolescent smoking; Self-reported smoking; Cotinine-validated smoking; Parental income; Misreporting; Concentration index

Cancer mortality trends in South Africa: 1997 - 2016

Background. Upon the addition of the numbers corresponding to various cancer anatomical locations in the report published by Statistics South Africa (StatsSA), the absolute number and proportion of deaths due to all cancers increased from 36 726 (8.0%) in 2013 to 40 460 (8.5%) in 2015. These high figures suggest that malignant neoplasms were in fact the second-most frequent cause of death in South Africa (SA) in 2013, and moved to the first rank in 2015. Objectives. To support the initiative aimed at reducing cancer mortality in SA. To this purpose, we assessed trends in cancer mortality rates among males and females in SA from 1997 to 2016 to better understand the increasing threat of cancer mortality in SA. Methods. The general mortality data for the period 1997 - 2016, as captured from death certificates in SA, was retrieved from StatsSA. Agestandardised mortality rates (ASMR) for each year were computed using the world standard population structure proposed by Segi as the reference population. The adjusted rates were reported per 100 000 population per year. The years of potential productive life lost (YPPLL) due to cancer deaths were calculated for each age group and gender. Results. There were 681  689 total cancer deaths from 1997 to 2016, with 51.1% males and 48.9% females. Males had higher mortality rates than females. The ASMR ranged from 105.0 to 129.2 and 67.9 to 88.3 per 100 000 population per year among males and females, respectively. In 2004, the cancer mortality rate increased significantly among males (129.2 per 100 000 population), which was 1.5 times higher than in females (88.3 per 100 000 population). Among males, cancer of the lung had the highest YPPLL (394 779.3), followed by oesophageal (253 989.4) and liver (207 911.0). The YPPLL for cancer of the cervix (647 855.5) ranked first, followed by breast (483 863.6) and lung (146 304.6) in females. Conclusion. Cancer mortality rates have increased since 1997, regardless of gender. Overall, there was a decline in YPPLL for cancer in the young population, while it increased in the adult population. A significant reduction in cancer deaths could be achieved by broadly applying effective intervention

Cost-effectiveness of remdesivir and dexamethasone for COVID-19 treatment in South Africa

Background Dexamethasone and remdesivir have the potential to reduce coronavirus disease 2019 (COVID)–related mortality or recovery time, but their cost-effectiveness in countries with limited intensive care resources is unknown. Methods We projected intensive care unit (ICU) needs and capacity from August 2020 to January 2021 using the South African National COVID-19 Epi Model. We assessed the cost-effectiveness of (1) administration of dexamethasone to ventilated patients and remdesivir to nonventilated patients, (2) dexamethasone alone to both nonventilated and ventilated patients, (3) remdesivir to nonventilated patients only, and (4) dexamethasone to ventilated patients only, all relative to a scenario of standard care. We estimated costs from the health care system perspective in 2020 US dollars, deaths averted, and the incremental cost-effectiveness ratios of each scenario. Results Remdesivir for nonventilated patients and dexamethasone for ventilated patients was estimated to result in 408 (uncertainty range, 229–1891) deaths averted (assuming no efficacy [uncertainty range, 0%–70%] of remdesivir) compared with standard care and to save 15 million US dollars. This result was driven by the efficacy of dexamethasone and the reduction of ICU-time required for patients treated with remdesivir. The scenario of dexamethasone alone for nonventilated and ventilated patients requires an additional 159 000 US dollars and averts 689 [uncertainty range, 330–1118] deaths, resulting in 231 US dollars per death averted, relative to standard care. Conclusions The use of remdesivir for nonventilated patients and dexamethasone for ventilated patients is likely to be cost-saving compared with standard care by reducing ICU days. Further efforts to improve recovery time with remdesivir and dexamethasone in ICUs could save lives and costs in South Africa