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

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

Experimental Studies of the Electrical Nonlinear Bimodal Transmission Line

After a few years of calm, the investigations on the dynamic, especially nonlinear, systems returned to the front of the research in non-linear physics. We propose, in this chapter, a study of an electrical nonlinear transmission line, realized in a previous work, to use the latter to highlight certain properties (modulation instability—MI, Fermi-Pasta-Ulam (FPU) recurrence, fragmentation of solitons in wave trains, multiplication(increase) and division of frequencies, etc.), which are observed in several domains in applied physics: hydraulic, artificial neuronal, network physical appearance (physics) of the plasma, and the circulation

Proposition de la mise en place du modèle ISO 45001 version 2018 : cas des entreprises industrielles de Ségou

Dans un contexte marqué par la révolution technologique des entreprises pour faire plus de productivité a constitué l’environnement de celles-ci plus accidentogène. Or, la protection des travailleurs défendue tant de législation internationale que nationale, les entreprises cherchent à créer un environnement plus protecteur en développant une approche globale de la gestion des questions de la santé et de la sécurité au travail. A cet effet, le modèle ISO : 45001 est vu comme un système de management de la SST qui pourrait répondre à ce besoin de management de la SST. Par conséquent, ce modèle permet aux entreprises d’être plus performantes en matière de la SST et surtout d’avoir un environnement protecteur, un comportement en SST efficace. A la différence des autres chercheurs, notre étude définit et établit une relation positive entre le processus de mise en place du modèle ISO : 45001 et les leaderships transformationnel et transactionnel. Les données relatives à cette étude ont été collectées à travers les entretiens collectifs effectués auprès de 22 personnes de trois entreprises. Cette étude a démontré que ces deux types de leaderships sont indispensables dans le processus et la mise en place du modèle ISO : 45001

Combinatorial kk-systoles on a punctured torus and a pair of pants

In this paper, $S$ denotes a surface homeomorphic to a punctured torus or a pair of pants. Our interest is the study of \emph{\textbf{combinatorial $k$-systoles}} that is closed curves with self-intersection numbers greater than $k$ and with least combinatorial length. We show that the maximal intersection number $I^c_k$ of combinatorial $k$-systoles of $S$ grows like $k$ and $\underset{k\rightarrow+\infty}{\limsup}(I^c_k-k)=+\infty$. This result, in case of a pair of pants and a punctured torus, is a positive response to the combinatorial version of the Erlandsson - Parlier conjecture, originally formulated for the geometric length.Comment: 12 pages, 8 figure

Evaluation de L’efficacite et de L’acceptabilite de la Prise en Charge Ambulatoire de la Malnutrition Aigue Chez les Enfants Vivants Avec le Vih (Evvih) Au Centre Hospitalier Regional De Ziguinchor (Chrz)/ Senegal

Objectif : La malnutrition aigüe est fréquente chez les enfants infectés par le VIH. L’objectif de notre travail était d’évaluer l’efficacité et l’acceptabilité des protocoles de récupération nutritionnelle ambulatoire basés sur les aliments prêts à l’emploi (ATPE) chez les EVVIH. Matériel et méthodes : Il s’agissait d’une étude prospective, réalisée à la pédiatrie du CHRZ du 7 janvier au 31 Septembre 2018. Ont été inclus les EVVIH, âgés de 6 mois à 19 ans présentant une malnutrition aigüe modérée ou sévère sans complication. Le suivi était bimensuel jusqu’à l’atteinte du poids cible. Un bilan clinico-biologique et anthropométrique, la délivrance des ATPE et la mesure de l’observance aux prescriptions étaient réalisés. Résultats : Douze enfants vivants avec le VIH ont été inclus dont 3 MAS et 9 MAM sur un total de 25 enfants suivis soit une prévalence de 48%. Le sexe ratio (1,4) en faveur des garçons. L’âge médian (9,5 ans). Ils étaient sous ARV dans 92% des cas. La moitié des patients avait un âge > à 10 ans. La toux était le symptôme le plus retrouvé (67%) suivie de la diarrhée (58,3%), des vomissements (8,3%), une otite moyenne chronique (8,3%). La charge virale au début de l'étude a montré (5cas < 50 copies, 3cas < 5000 copies, 4cas > 15 000 copies). Le taux d'hémoglobine était < 10g/dl dans 92% des cas. Un problème d'observance de la prise d'ATPE a été noté dans 58,3%. Onze enfants ont atteint leur poids cible. Nous n’avons pas noté de perdu de vu ni d’hospitalisé. Conclusion : Les ATPE bien que efficaces, pausent souvent un problème d’acceptabilité. On gagnerait à améliorer le gout et la présentation pour permettre une meilleure observance. Objective: Acute malnutrition is common in children with HIV infection. The objective of our work was to evaluate the efficiency and acceptability of ambulatory nutritional recovery protocols (ATPE) based on ready-to-use food) in HIV-positive children (EVVIH). Methods: This was a prospective study, conducted at the pediatrics of the regional hospital center of Ziguinchor (CHRZ) from January 7th to September 31st, 2018. We included all HIV-positive children (EVVIH), aged between 6 months and 19 years with relatively acute or severe malnutrition without complication. The follow-up was done every two months until target weight was reached. A clinic-biological and anthropometric report, the issuing of ATPE and the measurement of compliance with prescriptions were carried out. Results: We chose 12 children living with HIV, including 3 MAS and 9 MAM out of a total of 25 children followed, with a prevalence of 48%. The sex ratio (1.4) was in favor of boys. The medium age was (9.5 years). They were under ARV in 92% of cases. Half of the patients were > 10 years old. Coughing was the most common symptom (67%) followed by diarrhea (58.3%), vomiting (8.3%), medium chronic otitis (8.3%). The viral affection at the beginning of the study showed (5cases <50 copies, 3cases <5000 copies, 4cases> 15,000 copies). The hemoglobin level was <10g / dl in 92% of cases. A problem of respect of ATPE taking was noted in 58.3%. Eleven children reached their target weight. We did not notice any loss ofsight and no child was hospitalized. Conclusion: Although the ATPE are efficient, they often cause a problem of acceptability. It would be better to improve the taste and the presentation to allow a better observance