Examining inequities in incidence of catastrophic health expenditures on different healthcare services and health facilities in Nigeria.

OBJECTIVE: There is limited evidence about levels of socio-economic and other differences in catastrophic health spending in Nigeria and in many sub-Saharan African countries. The study estimated the level of catastrophic healthcare expenditures for different healthcare services and facilities and their distribution across socioeconomic status (SES) groups. METHODS: The study took place in four Local Government Areas in southeast Nigeria. Data were collected using interviewer-administered questionnaires administered to 4873 households. Catastrophic health expenditures (CHE) were measured using a threshold of 40% of monthly non-food expenditure. We examined both total monthly health expenditure and disaggregated expenditure by source and type of care. RESULTS: The average total household health expenditure per month was 2354 Naira ($19.6). For outpatient services, average monthly expenditure was 1809 Naira ($15.1), whilst for inpatient services it was 610 Naira ($5.1). Higher health expenditures were incurred by urban residents and the better-off SES groups. Overall, 27% of households incurred CHE, higher for poorer socioeconomic groups and for rural residents. Only 1.0% of households had a member that was enrolled in a health insurance scheme. CONCLUSION: The worse-off households (the poorest SES and rural dwellers) experienced the highest burden of health expenditure. There was almost a complete lack of financial risk protection. Health reform mechanisms are needed to ensure universal coverage with financial risk protection mechanisms

Valuing the benefits of a health intervention using three different approaches to contingent valuation: re-treatment of mosquito bed-nets in Nigeria.

OBJECTIVES: To determine the level of willingness to pay (WTP) for re-treatment of mosquito nets and to compare the theoretical validity of WTP estimates from three contingent valuation question formats: the bidding game, binary with follow-up technique, and a novel structured haggling technique that mimicked price-taking behaviour in the study area. METHODS: WTP was elicited from randomly selected respondents from three villages in Southeast Nigeria, using pretested interviewer-administered questionnaires. Respondents' WTP for insecticide-treated nets (ITNs) was first elicited before their WTP for re-treatment of ITNs. Ordinary least-squares regression was used to assess theoretical validity. RESULTS: More than 95% of the respondents were willing to pay for re-treatment. The mean WTP was 37.1 Naira, 43.4 Naira and 49.2 Naira in the bidding game, binary with follow-up and structured haggling groups, respectively (US dollar 1.00 = 120 Naira). The WTP estimates elicited across the three question formats were statistically different (P < 0.01). Ordinary least-squares estimation showed that WTP was positively related to many variables, especially stated WTP for ITNs (P < 0.05). Structured haggling generated the highest number of statistically significant variables to explain WTP. CONCLUSIONS: The three contingent valuation approaches generated different distributions of WTP for net retreatment, possibly due to their inherent differences. Structured haggling generated the most theoretically valid estimates of WTP. The levels of WTP identified suggest that user fees exceeding 50 Naira per net re-treatment may discourage demand for the service. This is an important challenge for ITN programmes

Costing the distribution of insecticide-treated nets: a review of cost and cost-effectiveness studies to provide guidance on standardization of costing methodology

BACKGROUND: Insecticide-treated nets (ITNs) are an effective and cost-effective means of malaria control. Scaling-up coverage of ITNs is challenging. It requires substantial resources and there are a number of strategies to choose from. Information on the cost of different strategies is still scarce. To guide the choice of a delivery strategy (or combination of strategies), reliable and standardized cost information for the different options is required. METHODS: The electronic online database PubMed was used for a systematic search of the published English literature on costing and economic evaluations of ITN distribution programmes. The keywords used were: net, bednet, insecticide, treated, ITN, cost, effectiveness, economic and evaluation. Identified papers were analysed to determine and evaluate the costing methods used. Methods were judged against existing standards of cost analysis to arrive at proposed standards for undertaking and presenting cost analyses. RESULTS: Cost estimates were often not readily comparable or could not be adjusted to a different context. This resulted from the wide range of methods applied and measures of output chosen. Most common shortcomings were the omission of certain costs and failure to adjust financial costs to generate economic costs. Generalisability was hampered by authors not reporting quantities and prices of resources separately and not examining the sensitivity of their results to variations in underlying assumptions. CONCLUSION: The observed shortcomings have arisen despite the abundance of literature and guidelines on costing of health care interventions. This paper provides ITN specific recommendations in the hope that these will help to standardize future cost estimates

Are malaria treatment expenditures catastrophic to different socio-economic and geographic groups and how do they cope with payment? A study in southeast Nigeria.

OBJECTIVES: To determine the inequities in the household income depletion resulting from malaria treatment expenditures, the sacrifice of basic household needs (catastrophe) and the differences in payment strategies among different socio-economic and geographic groups in southeast Nigeria. METHODS: Data were gathered through pre-tested, structured questionnaires from a random sample of 2 250 householders in rural and urban parts of southeast Nigeria. The level of catastrophic malaria treatment expenditure was computed as the percentage of average monthly malaria treatment expenditure divided by the average monthly non-food household expenditure, using a threshold of 5%. Socio-economic inequity was established using a socio-economic status (SES) index, while a rural-urban comparison examined geographic disparities. RESULTS: The average cost to treat a case of malaria was 796.5 Naira ($6.64) for adults and 789.0 Naira ($6.58) for children. The monthly malaria treatment expenditure as a proportion of monthly household non-food expenditure was 7.8%, 8.5%, 5.5% and 3.9% for the most poor, very poor, poor and least poor SES groups respectively. Malaria treatment accounted for 7.1% and 5.0% of non-food expenditures for rural and urban dwellers, respectively. More than 95% of the people financed their treatment through out-of-pocket payment (OOP), with no SES and rural-urban variance, as opposed to insurance payment mechanisms and fee exemptions. CONCLUSION: There were socio-economic and geographic inequities in the financial burden resulting from malaria treatment. The treatment expenditure depleted more of the aggregate income of the two worse-off SES (Q1 and Q2) and of the rural dwellers. Government and donor agencies should institute the abolition of user fees for malaria, the transition from OOP to pre-payment mechanisms and the improvement of physical access to appropriate malaria treatment services, as well as subsidies and deferrals in order to engender financial risk protection from malaria treatment

The efficiency of the local health systems: investigating the roles of health administrations and health care providers

The analysis of efficiency in health care has largely focused either on individual health care providers, or on sub-national health systems conceived as a unique decision-making unit. However, in hierarchically organized national health services, two separate entities are responsible for turning financial resources into services at the local level: health administrations and health care providers. Their separate roles and the one of health administrations in particular have not been explicitly considered in efficiency analysis. We applied stochastic frontier analysis to district-level panel data from Mozambique (2008-2011) to assess district efficiency in delivering outpatient care. We first assessed the efficiency of the whole district considered as an individual decision-making unit, and then we assessed separately the efficiency of health administrations and health care providers within the same district. We found that on average only 73% of the outpatient consultations deliverable using available inputs were realized, with large differences in performance across districts. Individual districts performed differently in administrative or health care delivery functions. On average, a reduction of administrative inefficiency by 10 percentage points, for a given expenditure would increase by 0.2% the volume of services delivered per thousand population per year. Identifying and targeting the specific drivers of administrative inefficiencies can contribute to increase service

Testing times: trends in availability, price, and market share of malaria diagnostics in the public and private healthcare sector across eight sub-Saharan African countries from 2009 to 2015.

BACKGROUND: The World Health Organization guidelines have recommended that all cases of suspected malaria should receive a confirmatory test with microscopy or a malaria rapid diagnostic test (RDT), however evidence from sub-Saharan Africa (SSA) illustrates that only one-third of children under five with a recent fever received a test. The aim of this study was to evaluate availability, price and market share of microscopy and RDT from 2009/11 to 2014/15 in 8 SSA countries, to better understand barriers to improving access to malaria confirmatory testing in the public and private health sectors. RESULTS: Repeated national cross-sectional quantitative surveys were conducted among a sample of outlets stocking anti-malarial medicines and/or diagnostics. In total, 169,655 outlets were screened. Availability of malaria blood testing among all screened public health facilities increased significantly between the first survey wave in 2009/11 and the most recent in 2014/15 in Benin (36.2, 85.4%, p < 0.001), Kenya (53.8, 93.0%, p < 0.001), mainland Tanzania (46.9, 89.9%, p < 0.001), Nigeria (28.5, 86.2%, p < 0.001), Katanga, the Democratic Republic of the Congo (DRC) (76.0, 88.2%, p < 0.05), and Uganda (38.9, 95.6%, p < 0.001). These findings were attributed to an increase in availability of RDTs. Diagnostic availability remained high in Kinshasa (the DRC) (87.6, 97.6%) and Zambia (87.9, 91.6%). Testing availability in public health facilities significantly decreased in Madagascar (88.1, 73.1%, p < 0.01). In the most recent survey round, the majority of malaria testing was performed in the public sector in Zambia (90.9%), Benin (90.3%), Madagascar (84.5%), Katanga (74.3%), mainland Tanzania (73.5%), Uganda (71.8%), Nigeria (68.4%), Kenya (53.2%) and Kinshasa (51.9%). In the anti-malarial stocking private sector, significant increases in availability of diagnostic tests among private for-profit facilities were observed between the first and final survey rounds in Kinshasa (82.1, 94.0%, p < 0.05), Nigeria (37.0, 66.0%, p < 0.05), Kenya (52.8, 74.3%, p < 0.001), mainland Tanzania (66.8, 93.5%, p < 0.01), Uganda (47.1, 70.1%, p < 0.001), and Madagascar (14.5, 45.0%, p < 0.01). Blood testing availability remained low over time among anti-malarial stocking private health facilities in Benin (33.1, 20.7%), and high over time in Zambia (94.4, 87.5%), with evidence of falls in availability in Katanga (72.7, 55.6%, p < 0.05). Availability among anti-malarial stocking pharmacies and drug stores-which are the most common source of anti-malarial medicines-was rare in all settings, and highest in Uganda in 2015 (21.5%). Median private sector price of RDT for a child was equal to the price of pre-packaged quality-assured artemisinin-based combination therapy (QAACT) treatment for a two-year old child in some countries, and 1.5-2.5 times higher in others. Median private sector QAACT price for an adult varied from having parity with an RDT for an adult to being up to 2 times more expensive. The exception was in both Kinshasa and Katanga, where the median price of QAACT was less expensive than RDTs. CONCLUSIONS: Significant strides have been made in the availability of testing, mainly through the widespread distribution of RDT, and especially in public health facilities. Significant barriers to universal coverage of diagnostic testing can be attributed to very low availability in the private sector, particularly among pharmacies and drug stores, which are responsible for most anti-malarial distribution. Where tests are available, price may serve as a barrier to uptake, particularly for young children. Several initiatives that have introduced RDT into the private sector can be modified and expanded as a means to close this gap in malaria testing availability and promote universal diagnosis

Health service availability and health seeking behaviour in resource poor settings: evidence from Mozambique.

Low-income countries are plagued by a high burden of preventable and curable disease as well as unmet need for healthcare, but detailed microeconomic evidence on the relationship between supply-side factors and service use is limited. Causality has rarely been assessed due to the challenges posed by the endogeneity of health service supply.In this study, using data from Mozambique, we investigate the effect of healthcare service availability, measured as the type of health facilities and their level of staffing and equipment, on the individual decision to seek care. We apply an instrumental variable approach to test for causality in the effect of staff and equipment availability on the decision to seek care and we explore heterogeneous effects based on the distance of households to the closest health facility.We find that living in the proximity of a health facility increases the probability of seeking care. A greater availability of referral health services in the locality has no significant effect on decision to seek care, while greater availability of staff and equipment increases the probability of seeking care when ill. Demand side barriers to health care use exist, but have a smaller impact when health care services are available within one hour walking distance

Evasion of "mandatory" social health insurance for the formal sector: evidence from Lao PDR.

BACKGROUND: In the last decade, almost every low- or middle-income country in the world has expressed support for universal health coverage (UHC). While at the beginning of the UHC movement, country strategies focused on increasing access to the formal sector as the first step of UHC, there is now consensus that countries should cover the entire population, with particular attention to covering the poor. However, it is often assumed that mandatory schemes will automatically cover their target populations, and consequently little is known about why firms comply or do not comply with enrolment requirements. Using the experience of Lao PDR, where the enrolment rate in the mandatory social security scheme is low and the capacity for regulation is weak, we conducted this study to better understand the determinants of enrolment of private sector firms in mandatory social security. METHODS: We used a cross-sectional case-comparison design, surveying 130 firms. We applied a structured questionnaire to explore determinants of enrolment, specifically looking at firm characteristics (e.g., industry category, ownership); sociodemographic characteristics of company heads; firms' risk perceptions; details of employment contracts; employee benefits; and exposure to social security. Closed ended questions were analysed quantitatively, while content analysis was applied to open-ended questions. Logistic regression was used to examine the determinants of enrolment. RESULTS: Smaller privately owned firms in the services industry were the least likely to enrol in social security, while firms in the trade industry were more likely to enrol than firms in manufacturing, construction, or services. The main reason for not enrolling was that firms offered a better package of benefits to their employees, although further investigation of company benefits showed that this was not the case in practice. Additional reasons for non-compliance were lack of knowledge and poor quality of care at government hospitals. CONCLUSIONS: The study contributes to the dialogue on how best to increase coverage in the formal sector, which is an important element of achieving UHC. It also provides much needed information about the motivation of private sector firms to comply with mandatory schemes