Resource flows for health care: Namibia reproductive health sub-accounts

<p>Abstract</p> <p>Background</p> <p>Implementing initiatives to achieve the targets of MDG 5 requires sufficient financial resources that are mobilized and utilized in an equitable, efficient and sustainable manner. Informed decision making to this end requires the availability of reliable health financing information. This is accomplished by means of Reproductive Health (RH) sub-account, which captures and organizes expenditure on RH services in two-dimensional tables from financing sources to end users. The specific objectives of this study are: (i) to quantify total expenditure on reproductive health services; and (ii) to examine the flow of RH funds from sources to end users.</p> <p>Methods</p> <p>The RH sub-account was part of the general National Health Accounts exercise covering the Financial Years 2007/08 and 2008/09. Primary data were collected from employers, medical aid schemes, donors and government ministries using questionnaire. Secondary data were obtained from various documents of the Namibian Government and the health financing database of the World Health Organization. Data were analyzed using a data screen designed in Microsoft Excel.</p> <p>Results</p> <p>RH expenditure per woman of reproductive age was US$148 and US$ 126 in the 2007/08 and 2008/09 financial years respectively. This is by far higher than what is observed in most African countries. RH expenditure constituted more than 10-12% of the total expenditure on health. Out-of-pocket payment for RH was minimal (less than 4% of the RH spending in both years). Government is the key source of RH spending. Moreover, the public sector is the main financing agent with programmatic control of RH funds and also the main provider of services. Most of the RH expenditure is spent on services of curative care (both in- and out-patient). The proportion allocated for preventive and public health services was not more than 5% in the two financial years.</p> <p>Conclusion</p> <p>Namibia's expenditure on reproductive health is remarkable by the standards of Africa and other middle-income countries. However, an increasing maternal mortality ratio does not bode well with the level of reproductive health expenditure. It is therefore important to critically examine the state of efficiency in the allocation and use of reproductive health expenditures in order to improve health outcomes.</p

Performance-based financing kick-starts motivational “feedback loop”: findings from a process evaluation in Mozambique

Background: Performance-based financing (PBF) reforms aim to directly influence health worker behavior through changes to institutional arrangements, accountability structures, and financial incentives based on performance. While there is still some debate about whether PBF influences extrinsic or intrinsic motivators, recent research finds that PBF affects both. Against this backdrop, our study presents findings from a process evaluation of a PBF program in Mozambique, exploring the perceived changes to both internal and external drivers of health worker motivation associated with PBF. Methods: We used a qualitative research design with in-depth, semi-structured interviews with health workers, which included a rank order exercise and focus group discussions. Interviews were analyzed by two researchers using thematic analysis techniques. Rank order frequency was calculated using weighted average methodology. Results: Health workers reported that PBF, overall, positively influenced their motivation by introducing or reinforcing both internal and external motivational drivers. Internal drivers included enhanced self-efficacy driven by goal orientation, healthy competition among colleagues, and job satisfaction. External drivers included an organized work environment, enhanced access to equipment and supplies, financial incentives, teamwork, and regular consultations with verifiers (a type of supervision). PBF stimulates an interactive relationship between internal and external motivational drivers, creating a feedback loop involving responsibility, achievement, and recognition, which increased perceived motivation. Conclusions: The PBF program helped workers feel that they had well-defined and achievable goals and that they received recognition from verification teams, management committees, and colleagues due to enhanced accountability and governance. Our paper shows that financial incentives could serve as the “driver” to kick-start the feedback loop, of responsibility, achievement, and recognition, in environments that lack other drivers. Understanding how PBF programs can be designed and refined to reinforce this feedback loop could be a powerful tool to further enhance and track positive motivational changes. For countries thinking about PBF, we recommend that policymakers assess the loop in their contexts, identify drivers, determine whether these drivers are sufficient, and consider PBF if they are not. Trial registration: We obtained ethical approval for the study protocol, data collection instruments, and informed consent forms from the Ethics Review Committee of the Centers for Disease Control and Prevention (CDC) [IRB 2015–190] and the Ethics Review Committee of the Mozambique Ministry of Health

Accelerating Kenya's progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015.

INTRODUCTION: Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for reducing under-five mortality. To accelerate progress to 2030, we must understand what impacted mortality throughout the MDG period. METHODS: Trends in the under-five mortality rate (U5MR) were analysed using data from nationally representative Demographic and Health Surveys (1989-2014). Comprehensive, mixed-methods analyses of health policies and systems, workforce and health financing were conducted using relevant surveys, government documents and key informant interviews with country experts. A hierarchical multivariable linear regression analysis was undertaken to better understand the proximal determinants of change in U5MR over the MDG period. RESULTS: U5MR declined by 50% from 1993 to 2014. However, mortality increased between 1990 and 2000, following the introduction of facility user fees and declining coverage of essential interventions. The MDGs, together with Kenya's political changes in 2003, ushered in a new era of policymaking with a strong focus on children under 5 years of age. External aid for child health quadrupled from 40 million in 2002 to 180 million in 2012, contributing to the dramatic improvement in U5MR throughout the latter half of the MDG period. Our multivariable analysis explained 44% of the decline in U5MR from 2003 to 2014, highlighting maternal literacy, household wealth, sexual and reproductive health and maternal and infant nutrition as important contributing factors. Children living in Nairobi had higher odds of child mortality relative to children living in other regions of Kenya. CONCLUSIONS: To attain the Sustainable Development Goal targets for child health, Kenya must uphold its current momentum. For equitable access to health services, user fees must not be reintroduced in public facilities. Support for maternal nutrition and reproductive health should be prioritised, and Kenya should acknowledge its changing demographics in order to effectively manage the escalating burden of poor health among the urban poor

A "Politically Robust" Experimental Design for Public Policy Evaluation, with Application to the Mexican Universal Health Insurance Program

We develop an approach to conducting large scale randomized public policy experiments intended to be more robust to the political interventions that have ruined some or all parts of many similar previous efforts. Our proposed design is insulated from selection bias in some circumstances even if we lose observations; our inferences can still be unbiased even if politics disrupts any two of the three steps in our analytical procedures; and other empirical checks are available to validate the overall design. We illustrate with a design and empirical validation of an evaluation of the Mexican Seguro Popular de Salud (Universal Health Insurance) program we are conducting. Seguro Popular, which is intended to grow to provide medical care, drugs, preventative services, and financial health protection to the 50 million Mexicans without health insurance, is one of the largest health reforms of any country in the last two decades. The evaluation is also large scale, constituting one of the largest policy experiments to date and what may be the largest randomized health policy experiment ever.Governmen

Examining the implementation of the Linda Mama free maternity program in Kenya

Background In 2013, Kenya introduced a free maternity policy in all public healthcare facilities. In 2016, the Ministry of Health shifted responsibility for the program, now called Linda Mama, to the National Hospital Insurance Fund (NHIF) and expanded access beyond public sector. This study aimed to examine the implementation of the Linda Mama program. Methods We conducted a mixed-methods cross-sectional study at the national level and in 20 purposively sampled facilities across five counties in Kenya. We collected data using in-depth interviews (n = 104), administered patient-exit questionnaires (n = 108), and carried out document reviews. Qualitative data were analysed using a framework approach while quantitative data were analysed descriptively. Results Linda Mama was designed and resulted in improved accountability and expand benefits. In practice however, beneficiaries did not access some services that were part of the revised benefit package. Second, out of pocket payments were still being incurred by beneficiaries. Health facilities in most counties had lost financial autonomy and had no access to reimbursements from NHIF for services provided; but those with financial autonomy were able to boost facility revenue and enhance service delivery. Further, fund disbursements from NHIF were characterised by delays and unpredictability. Implementation experiences reveal that there was inadequate communication, claim processing challenges and reimbursement rates were deemed insufficient

Public Policy for the Poor? A Randomised Assessment of the Mexican Universal Health Insurance Programme

Background: We assessed aspects of Seguro Popular, a programme aimed to deliver health insurance, regular and preventive medical care, medicines, and health facilities to 50 million uninsured Mexicans. Methods: We randomly assigned treatment within 74 matched pairs of health clusters—ie, health facility catchment areas—representing 118 569 households in seven Mexican states, and measured outcomes in a 2005 baseline survey (August, 2005, to September, 2005) and follow-up survey 10 months later (July, 2006, to August, 2006) in 50 pairs (n=32 515). The treatment consisted of encouragement to enrol in a health-insurance programme and upgraded medical facilities. Participant states also received funds to improve health facilities and to provide medications for services in treated clusters. We estimated intention to treat and complier average causal effects non-parametrically. Findings: Intention-to-treat estimates indicated a 23% reduction from baseline in catastrophic expenditures (1·9% points; 95% CI 0·14–3·66). The effect in poor households was 3·0% points (0·46–5·54) and in experimental compliers was 6·5% points (1·65–11·28), 30% and 59% reductions, respectively. The intention-to-treat effect on health spending in poor households was 426 pesos (39–812), and the complier average causal effect was 915 pesos (147–1684). Contrary to expectations and previous observational research, we found no effects on medication spending, health outcomes, or utilisation. Interpretation: Programme resources reached the poor. However, the programme did not show some other effects, possibly due to the short duration of treatment (10 months). Although Seguro Popular seems to be successful at this early stage, further experiments and follow-up studies, with longer assessment periods, are needed to ascertain the long-term effects of the programme. Funding: Mexican Ministry of Health, the National Institute of Public Health of Mexico, and Harvard University Institute for Quantitative Social ScienceGovernmen

Quercetin activates vitamin D receptor and ameliorates breast cancer induced hepatic inflammation and fibrosis

AimsTo explore the hepatoprotective role of quercetin and its novel molecular mechanism of action on breast cancer associated hepatic inflammation and fibrosis via Vitamin D receptor (VDR).Main methodsWe used Ehrlich Ascites Carcinoma (mouse mammary carcinoma) model for our in-vivo experiments and human breast cancer cell lines for in-vitro assays. We inoculated 1.5 × 106 Ehrlich ascites carcinoma cells into female Swiss albino mice. Quercetin (50 mg/kg) was administered intraperitoneally for 15 days. Liver enzymes activity was determined using a spectrophotometric assay. The hallmarks of inflammation and fibrosis were determined using Immunohistochemistry. The effect of quercetin on tumor formation was elucidated using human breast cancer cell lines and chick chorioallantoic membrane assay. Docking study was performed to explore the binding mode of quercetin with VDR.Key findingsIn EAC tumor-bearing mice, cell numbers, tumor volume, body weight and liver weight were dramatically increased, while they significantly decreased in mice treated with quercetin. Additionally, the peritoneal neo-angiogenesis was also significantly suppressed in the quercetin-treated mice, compared to the control. In addition, quercetin treated EAC tumor bearing mice had lower levels of liver enzymes, decreased hepatic inflammation and fibrosis compared with EAC tumor bearing mice. Docking study confirmed VDR-quercetin interaction. Furthermore, in-vitro assays and chick chorioallantoic membrane assay revealed the Vitamin D mimicking effect of quercetin.SignificanceDietary flavonoid, quercetin could act as a promising therapeutic drug to suppress the breast cancer induced tumor angiogenesis, hepatic inflammation, and fibrosis possibly via activation of VDR

Countdown to 2015 country case studies: what can analysis of national health financing contribute to understanding MDG 4 and 5 progress?

Background: Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies. Methods: This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in the case studies to help interpret health-financing data. Results: Dramatic increases in health funding occurred since 2000, where the MDG agenda encouraged countries and donors to invest more resources on health. Most low-income countries relied on external support to increase health spending, with an average 20–64 % of total health spending from 2000 onwards. Middle-income countries relied more on government and household spending. RMNCH funding also increased since 2000, with an average increase of 119 % (2005–2010) for RMNH expenditures (2005–2010) and 165 % for CH expenditures (2005–2011). Progress was made, especially achieving MDG 4, even with low per capita spending; ranging from US$16 to US$44 per child under 5 years among low-income countries. Improvements in distal factors were noted during the time frame of the analysis, including rapid economic growth in Ethiopia, Peru, and Tanzania and improvements in female literacy as documented in Malawi, which are also likely to have contributed to MDG progress and achievements. Conclusions: Increases in health and RMNCH funding accompanied improvements in outcomes, though low-income countries are still very reliant on external financing, and out-of-pocket comprising a growing share of funds in middle-income settings. Enhancements in tracking RMNCH expenditures across countries are still needed to better understand whether domestic and global health financing initiatives lead to improved outcomes as RMNCH continues to be a priority under the Sustainable Development Goals. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3403-4) contains supplementary material, which is available to authorized users

Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?

Background: Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress. Methods: Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing). Results: The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30–40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers. Conclusions: These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3401-6) contains supplementary material, which is available to authorized users