Evidence for informing health policy development in Low- income Countries (LICs): perspectives of policy actors in Uganda

Background: Although there is a general agreement on the benefits of evidence informed health policy development given resource constraints especially in Low-Income Countries (LICs), the definition of what evidence is, and what evidence is suitable to guide decision-making is still unclear. Our study is contributing to filling this knowledge gap. We aimed to explore health policy actors’ views regarding what evidence they deemed appropriate to guide health policy development. Methods: Using exploratory qualitative methods, we conducted interviews with 51 key informants using an in- depth interview guide. We interviewed a diverse group of stakeholders in health policy development and knowledge translation in the Uganda health sector. Data were analyzed using inductive content analysis techniques. Results: Different stakeholders lay emphasis on different kinds of evidence. While donors preferred international evidence and Ministry of Health (MoH) officials looked to local evidence, district health managers preferred local evidence, evidence from routine monitoring and evaluation, and reports from service providers. Service providers on the other hand preferred local evidence and routine monitoring and evaluation reports whilst researchers preferred systematic reviews and clinical trials. Stakeholders preferred evidence covering several aspects impacting on decision-making highlighting the fact that although policy actors look for factual information, they also require evidence on context and implementation feasibility of a policy decision. Conclusion: What LICs like Uganda categorize as evidence suitable for informing policy encompasses several types with no consensus on what is deemed as most appropriate. Evidence must be of high quality, applicable, acceptable to the users, and informing different aspects of decision-makin

Health financing reform in Uganda: How equitable is the proposed National Health Insurance scheme?

<p>Abstract</p> <p>Background</p> <p>Uganda is proposing introduction of the National Health Insurance scheme (NHIS) in a phased manner with the view to obtaining additional funding for the health sector and promoting financial risk protection. In this paper, we have assessed the proposed NHIS from an equity perspective, exploring the extent to which NHIS would improve existing disparities in the health sector.</p> <p>Methods</p> <p>We reviewed the proposed design and other relevant documents that enhanced our understanding of contextual issues. We used the Kutzin and fair financing frameworks to critically assess the impact of NHIS on overall equity in financing in Uganda.</p> <p>Results</p> <p>The introduction of NHIS is being proposed against the backdrop of inequalities in the distribution of health system inputs between rural and urban areas, different levels of care and geographic areas. In this assessment, we find that gradual implementation of NHIS will result in low coverage initially, which might pose a challenge for effective management of the scheme. The process for accreditation of service providers during the first phase is not explicit on how it will ensure that a two-tier service provision arrangement does not emerge to cater for different types of patients. If the proposed fee-for-service mechanism of reimbursing providers is pursued, utilisation patterns will determine how resources are allocated. This implies that equity in resource allocation will be determined by the distribution of accredited providers, and checks put in place to prohibit frivolous use. The current design does not explicitly mention how these two issues will be tackled. Lastly, there is no clarity on how the NHIS will fit into, and integrate within existing financing mechanisms.</p> <p>Conclusion</p> <p>Under the current NHIS design, the initial low coverage in the first years will inhibit optimal achievement of the important equity characteristics of pooling, cross-subsidisation and financial protection. Depending on the distribution of accredited providers and utilisation patterns, the NHIS could worsen existing disparities in access to services, given the fee-for-service reimbursement mechanisms currently proposed. Lastly, if equity in financing and resource allocation are not explicit objectives of the NHIS, it might inadvertently worsen the existing disparities in service provision.</p

Can donor aid for health be effective in a poor country? Assessment of prerequisites for aid effectiveness in Uganda

Background: Inadequate funding for health is a challenge to attaining health-related Millennium Development Goals. Significant increase in health funding was recommended by the Commission for Macroeconomics and Health. Indeed Official Development Assistance has increased significantly in Uganda. However, the effectiveness of donor aid has come under greater scrutiny. This paper scrutinizes the prerequisites for aid effectiveness. The objective of the study was to assess the prerequisites for effectiveness of donor aid, specifically, its proportion to overall health funding, predictability, comprehensiveness, alignment to country priorities, and channeling mechanisms. Methods:Secondary data obtained from various official reports and surveys were analyzed against the variables mentioned under objectives. This was augmented by observations and participation in discussions with all stakeholders to discuss sector performance including health financing. Results:Between 2004−2007, the level of aid increased from US$6 per capita to US$11. Aid was found to be unpredictable with expenditure varying between 174−360 percent from budgets. More than 50% of aid was found to be off budget and unavailable for comprehensive planning. There was disproportionate funding for some items such as drugs. Key health system elements such as human resources and infrastructure have not been given due attention in investment. The government’s health funding from domestic sources grew only modestly which did not guarantee fiscal sustainability. Conclusion: Although donor aid is significant there is need to invest in the prerequisites that would guarantee its effective use

Monitoring Sustainable Development Goals 3: Assessing the Readiness of Low- and Middle-Income Countries

Background: The Millennium Development Goals (MDGs) availed opportunities for scaling up service coverage but called for stringent monitoring and evaluation (M&E) focusing mainly on MDG related programs. The Sustainable Development Goals 3 (SDGs) and the universal health coverage (UHC) agenda present a broader scope and require more sophisticated M&E systems. We assessed the readiness of low- and middle-income countries to monitor SDG 3.Methods: Employing mixed methods, we reviewed health sector M&E plans of 6 countries in the World Health Organization (WHO) Africa Region to assess the challenges to M&E, the indicator selection pattern and the extent of multisectoral collaboration. Qualitative data were analysed using content thematic analysis while quantitative data were analysed using Excel.Results: Challenges to monitoring SDG 3 include weak institutional capacity; fragmentation of M&E functions; inadequate domestic financing; inadequate data availability, dissemination and utilization of M&E products. The total number of indictors in the reviewed plans varied from 38 for Zimbabwe to 235 for Zanzibar. Sixty-nine percent of indicators for the Gambia and 89% for Zanzibar were not classified in any domain in the M&E results chain. Countries lay greater M&E emphasis on service delivery, health systems, maternal and child health as well as communicable diseases with a seeming neglect of the non-communicable diseases (NCDs). Inclusion of SDG 3 indicators only ranged from 48% for Zanzibar to 67% for Kenya. Although monitoring SDG 3 calls for multisectoral collaboration, consideration of the role of other sectors in the M&E plans was either absent or limited to the statistical departments. Conclusion: There are common challenges confronting M&E at county-level. Countries have omitted key indicators for monitoring components of the SDG 3 targets especially those on NCDs and injuries. The role of other sectors in monitoring SDG 3 targets is not adequately reflected. These could be bottlenecks to tracking progress towards SDG 3 if not addressed. Beyond providing compendium of indicators to guide countries, we advocate for a more binding minimum set of indicators for all countries to which they may add depending on their context. Ministries of Health (MoHs) should prioritise M&E as an important pillar for health service planning and implementation and not as an add-on activity

Cost of malaria morbidity in Uganda

Background: The high burden of malaria, among others, is a key challenge to both human and economic development in malaria endemic countries. The impact of malaria can be categorized from three dimensions, namely: health, social and economic. The economic dimension focuses on three types of effects, namely: direct, indirect and intangible effects which are felt at both macro and micro levels. The objective of this study was to estimate the costs of malaria morbidity in Uganda using the cost-of-illness approach. Methods: The study covered 4 districts, which were selected randomly after stratification by malaria endemicity into Hyper endemic (Kamuli and Mubende districts); Meso endemic (Mubende) and Hypo endemic (Kabale). A survey was undertaken to collect data on cost of illness at the household level while data on institutional costs was collected from the Ministry of Health and Development Partners. Results: Our study revealed that: (i) in 2003, the Ugandan economy lost a total of about US$658,200,599 (US$24.8 per capita) due to 12,343,411 cases malaria; (ii) the total consisted of US$49,122,349 (7$ 609,078,209 (92%) indirect costs or productivity losses; (iv) the total malaria treatment-related spending was US$46,134,999; out of which 90$2,987,351 was spent on malaria prevention; out of which 81% was borne by MOH and development partners. Conclusion: Malaria poses a heavy economic burden on households, which may expose them to financial catastrophe and impoverishment. This calls for the upholding of the no-user fees policy as well as increased investments in improving access to quality of health services and to proven community preventive interventions in order to further reduce the cost of illness borne by patients and their families

Economic Burden of Malaria in six Countries of Africa

Economic burden studies are important for use in advocating with Ministries of Finance and donors for increased investments in public health problems such as malaria. In September 2001, the authors convened a workshop at which a framework for the assessment of the economic burden of malaria in the African region was presented to health economists from 10 countries of the region. The framework document proposes the use of any one of three approaches – production function, cost of illness and willingness to pay – for the assessment of the burden of malaria to the economies of African countries. Between 2002 and 2005, six countries (Chad, Ghana, Mali, Nigeria, Rwanda and Uganda) undertook studies to assess the economic burden of malaria using the framework. The objective of this article is to report on the methodology, results and policy implications of the country economic burden studies. Of the six countries whose results are presented in this report, Ghana and Nigeria used all three approaches to estimate the economic burden of malaria. Uganda, Rwanda and Chad implemented the production function and the cost of illness approaches, while Mali used only the cost of illness approach. All countries implementing the cost of illness and willingness to pay approaches that required household surveys employed a multi-stage sampling methodology and used a structured questionnaire as the principal instrument for the collection of primary data from the households. Districts were selected to reflect the malaria epidemiological profile of the countries and a total of 5,498 households were sampled. Relevant secondary data on the institutional cost of malaria in the countries were obtained through checklists designed for the purpose, while other secondary data on the economy like the Gross Domestic Product (GDP), labour force, stock of capital, etc. were obtained from the National Statistical Services, Penn World Tables, World Bank Tables, African Development Bank, among others. Malaria was found to be a significant explanatory variable for national income in Chad, Ghana, Nigeria and Uganda, countries that estimated macroeconomic models to assess the impact on malaria on the economy. In these countries, the incidence of malaria had a negative impact on aggregate national output, with the loss in growth of the economy or the “malaria penalty†ranging from 0.41% in Ghana to as high as 3.8% and 8.9% in Nigeria and Chad respectively. The loss in economic growth in Rwanda is much smaller at 0.08%. The studies reveal that the impact of malaria on the growth in real gross domestic product is negative and decreases for every increase in malaria morbidity rates. The cost of illness approach results corroborate those obtained from the production function approach, indicating that malaria causes an enormous drain on the national economies. At the household level, the studies reveal a pattern of immense burden, particularly for the poorest households. In Ghana for example, the direct costs of malaria to the household is US$6.87, while it is US$ 11.84 and US$17.5 in Nigeria and Mali respectively. When the total cost of malaria was calculated, it was found that the countries were spending huge sums of resources for the control of malaria, resources that could have been devoted to other productive sectors, had the disease not been so prevalent. There is need for more investment in malaria endemic countries to combat the disease to at least US$ 1.5 billion to US$ 2.2 billion annually, levels advocated by the WHO Commission on Macroeconomics and Health, as these investments would lead to lives saved, enhanced productivity and improved quality of life, particularly for the most vulnerable population. Keywords: Africa, Malaria, Economic burden, Cost of illness, Direct costs, Indirect cost

Malaria Treatment Policy Change and Implementation: The Case of Uganda

Malaria due to P. falciparum is the number one cause of morbidity and mortality in Uganda where it is highly endemic in 95% of the country. The use of efficacious and effective antimalarial medicines is one of the key strategies for malaria control. Until 2000, Chloroquine (CQ) was the first-line drug for treatment of uncomplicated malaria in Uganda. Due to progressive resistance to CQ and to a combination of CQ with Sulfadoxine-Pyrimethamine, Uganda in 2004 adopted the use of ACTs as first-line drug for treating uncomplicated malaria. A review of the drug policy change process and postimplementation reports highlight the importance of managing the policy change process, generating evidence for policy decisions and availability of adequate and predictable funding for effective policy roll-out. These and other lessons learnt can be used to guide countries that are considering anti-malarial drug change in future

Cost of malaria morbidity in Uganda

The high burden of malaria, among others, is a key challenge to both human and economic development in malaria endemic countries. The impact of malaria can be categorized from three dimensions, namely: health, social and economic. The economic dimension focuses on three types of effects, namely: direct, indirect and intangible effects which are felt at both macro and micro levels. The objective of this study was to estimate the costs of malaria morbidity in Uganda using the cost-of-illness approach. The study covered 4 districts, which were selected randomly after stratification by malaria endemicity into Hyper endemic (Kamuli and Mubende districts); Meso endemic (Mubende) and Hypo endemic (Kabale). A survey was undertaken to collect data on cost of illness at the household level while data on institutional costs was collected from the Ministry of Health and Development Partners. Our study revealed that: (i) in 2003, the Ugandan economy lost a total of about US$658,200,599 (US$24.8 per capita) due to 12,343,411 cases malaria; (ii) the total consisted of US$49,122,349 (7$ 609,078,209 (92%) indirect costs or productivity losses; (iv) the total malaria treatment-related spending was US$46,134,999; out of which 90$2,987,351 was spent on malaria prevention; out of which 81% was borne by MOH and development partners.  Malaria poses a heavy economic burden on households, which may expose them to financial catastrophe and impoverishment. This calls for the upholding of the no-user fees policy as well as increased investments in improving access to quality of health services and to proven community preventive interventions in order to further reduce the cost of illness borne by patients and their families. Key words: Cost of illness, malaria, Ugand

Research-to-Policy Partnerships for Evidence-Informed Resource Allocation in Health Systems in Africa: An Example Using the Thanzi Programme

Objectives: Empirical data on the impact of research-to-policy interventions are scant, with the few attempts mainly focusing on ensuring policymakers’ timely access to evidence and evidence-informed dialogs. Methods: This article reflects on how the Thanzi Programme cultivates an approach of research-to-policy engagement in health economics. The program is structured around 3 interrelated pillars comprising research evidence generation, capacity and capability building, and research-and-policy engagement. Each pillar is described and examples from the Thanzi Programme are given, including illustrating how each pillar informs the other. Limitations and challenges of the approach are discussed, with examples of a way forward. Results: This program supports health system strengthening through addressing gaps identified by program partners. This includes providing health economics training and research and strengthened partnerships between in-country researchers and health policymakers, as well as between national and international researchers. Platforms bringing together researchers and policymakers to shape the research agenda, disseminate evidence, and foster an evidence-based dialog are institutionalized at country and regional levels. Health Economics and Policy Units have been established, which sit between the Ministries of Health and Universities, to augment policymakers and health economics researchers’ engagements on priority health policy matters and determine researchable policy questions. The establishment of the Health Economics Community of Practice as a substantive expert committee under the East Central and Southern Africa Health Community bolsters the contribution of health economics evidence in policy processes at the regional level. Conclusions: The Thanzi Programme is an example of how a research-and-policy partnership framework is being used to support evidence-informed health resource allocation decisions in Africa. It uses a combination of high-quality multidisciplinary research, sustained research and policymakers’ engagement and capacity strengthening to use research evidence to guide and support policy makers more effectively. Keywords: capacity building, health economics, knowledge translation, north-south partnership, research-to-policy engagement