Cost of care for preterm babies to Clients and influence of costs on care in resource limited settings - Societal perspective: A case of Jinja Regional Referral Hospital in East central Uganda

Introduction: The costs of care for preterm birth to clients and the influence of costs on preterm care remain a significant issue to the health system and families globally especially in the low-middle income countries particularly, in Asia and sub-Saharan Africa with already constrained economies. However, this has not received worthwhile attention. We estimated the costs of care for preterm babies to families (clients) and the influence of costs on the care for preterm babies from a societal perspective in Jinja Regional Referral Hospital. Methods: This was a one-month survey from August 2016 — September 2016 through which we had exit interviews with 100 mothers to determine the costs on admission and followed up 82 mothers to determine follow up costs of all babies that were born preterm and weighed less than 2.5 kg either at discharge or follow up. A micro costing approach was used to compute client costs for preterm care. Mothers were asked to identify absolute costs incurred. We also reviewed medical records of patients and receipts that were available from clients. A likert scale was used to assess influence of costs on preterm care to mothers. This ranged from -5 to 5, where (+5 to +1) was high influence, (0) was neutral, (-5 to -1) was low influence. Respondents were also asked to give reasons for their answers. From the provider perspective, we conducted key informant interviews with health care workers to ascertain the influence of costs on preterm care from the provider perspective. Analysis of findings was done using the Microsoft excel sheet. Statistical analysis was done using Stata Version 13 to determine the influence of costs on the care of preterm babies from the client's perspective. Thematic analysis was used to analyze the influence of costs on care from the provider perspective. Costs were converted to US$for the annual exchange average rate of 2016. One-way sensitivity analysis was done to establish the impact of cost drivers on the total cost. Results: The total annual cost of preterm care from the client perspective was US$ 10,520.36 and the unit cost of care per preterm baby was US$ 105.2 at Jinja Regional Referral Hospital. Cost drivers included opportunity costs (i.e., potential benefits foregone by clients to take care of preterm babies), drug costs on follow up, supplies and feeding costs to the mothers/caregivers during admission. Drugs, supplies thermal care and feeding costs during admission were found to have a high influence on preterm care from a societal perspective. Conclusion: The cost of preterm care is high from the client perspective and is characterized by longer stay in hospital because of missed treatment due to stock outs and affordability constraints to clients, but also discharge against medical advice leading to poor survival of preterm babies. Improving funding for preterm care and welfare for caregivers during hospitalization may lead to better outcomes for preterm babies

Isoniazid preventive therapy completion and factors associated with non-completion among patients on antiretroviral therapy at Kisenyi Health Centre IV, Kampala, Uganda.

BackgroundIsoniazid preventive therapy (IPT) is given to HIV patients to reduce the risk of active tuberculosis (TB). However, treatment completion remains suboptimal among those that are initiated. This study aimed to determine the completion level of IPT and the factors associated with non-completion among patients on antiretroviral therapy (ART) at Kisenyi Health Center IV in Kampala, Uganda.MethodsA mixed-methods facility-based retrospective cohort study utilizing routinely collected data from 341 randomly selected HIV patients initiated on IPT was conducted. Data extracted from the registers was used to determine IPT completion. Robust Poisson regression was conducted to determine the associated factors of IPT non-completion, while in-depth interviews were conducted to explore barriers to IPT completion from the patient's perspective.ResultsA total of 341 patients who started on isoniazid (INH) were retrospectively followed up, with 69% (236/341) being female. Overall IPT completion was 83%. Multivariate analysis revealed the prevalence of IPT non-completion among males was 2.24 times the prevalence among females (aPR 2.24, 95% CI: 1.40-3.58, p = 0.001). The prevalence of IPT non-completion among patients with a non-suppressed HIV viral load was 3.00 times the prevalence among those with a suppressed HIV viral load (aPR 3.00, 95% CI: 1.44-6.65, p = 0.007). The prevalence of IPT non-completion among patients who were married, or cohabiting was 0.31 times the prevalence among those who were single (aPR 0.31, 95% CI: 0.17-0.55, pConclusionIPT completion was found to be 83% among the cohort studied. However, lower completion levels persist among males and HIV-virally non-suppressed patients. Lack of IPT-related health education, pill burden, distance to the health facility, and patient relocation were reported as barriers to IPT completion. Interventions that target these groups of people need to be intensified

The economic burden of pneumonia in children under five in Uganda

Background: There were about 138 million new episodes of pneumonia and 0.9 million deaths globally in 2015. In Uganda, pneumonia was the fourth leading cause of death in children under five years of age in 2017–18. However, the economic burden of pneumonia, particularly for households and caregivers, is poorly documented. Aim: To estimate the costs associated with an episode of pneumonia from the household, government, and societal perspectives. Methods: We selected 48 healthcare facilities from the public and private sector across all care levels (primary, secondary, and tertiary), based on the number of pneumonia episodes reported for 2015–16. Adult caregivers of children with pneumonia diagnosis at discharge were selected. Using an ingredient-based approach, we collected cost and utilization data from administrative databases, medical records, and patient caregiver surveys. Household costs included direct medical and non-medical costs, as well as indirect costs estimated through a human capital approach. All costs are presented in 2018 U.S. dollars. Results: The treatment of pneumonia puts a substantial economic burden on households. The average societal cost per episode of pneumonia across all sectors and types of visits was $42; hospitalized episodes costed an average of$62 per episode, while episodes only requiring ambulatory care was $16 per episode. Public healthcare facilities covered$12 and $7 on average per hospitalized or ambulatory episode, respectively. Caregivers using the public system faced lower out-of-pocket payments, evaluated at$17, than those who used private for-profit ($21) and not-for-profit ($50) for hospitalized care. For ambulatory care, out-of-pocket payments amounted to $8,$18, and $9 for public, private for-profit, and not-for-profit healthcare facilities, respectively. About 39% of households experienced catastrophic health expenditures due to out-of-pocket payments related to the treatment of pneumonia

Health versus other sectors: Multisectoral resource allocation preferences in Mukono district, Uganda.

ObjectivesTo elicit citizen preferences for national budget resource allocation in Uganda, examine respondents' preferences for health vis-à-vis other sectors, and compare these preferences with actual government budget allocations.MethodsWe surveyed 432 households in urban and rural areas of Mukono district in central Uganda.We elicited citizens' preferences for resource allocation across all sectors using a best-worst scaling (BWS) survey. The BWS survey consisted of 16 sectors corresponding to the Uganda national budget line items. Respondents chose, from a subset of four sectors across 16 choice tasks, which sectors they thought were most and least important to allocate resources to. We utilized the relative best-minus-worst score method and a conditional logistic regression to obtain ranked preferences for resource allocation across sectors. We then compared the respondents' preferences with actual government budget allocations.ResultsThe health sector was the top ranked sector where 82% of respondents selected health as the most important sector for the government to fund, but it was ranked sixth in national budget allocation, encompassing 6.4% of the total budget. Beyond health, water and environment, agriculture, and social development sectors were largely underfunded compared to respondents' preferences. Works and transport, education, security, and justice, law and order received a larger share of the national budget compared to respondents' preferences.ConclusionsAmong respondents from Mukono district in Uganda, we found that citizens' preferences for resource allocation across sectors, including for the health sector, were fundamentally misaligned with current government budget allocations. Evidence of respondents' strong preferences for allocating resources to the health sector could help stakeholders make the case for increased health sector allocations. Greater investment in health is not only essential to satisfy citizens' needs and preferences, but also to meet the government's health goals to improve health, strengthen health systems, and achieve universal health coverage

Trends in access to anti‐malarial treatment in the formal private sector in Uganda: an assessment of availability and affordability of first‐line anti‐malarials and diagnostics between 2007 and 2018

Background: Malaria is the single largest cause of illness in Uganda. Since the year 2008, the Global Fund has rolled out several funding streams for malaria control in Uganda. Among these are mechanisms aimed at increasing the availability and affordability of artemisinin-based combination therapy (ACT). This paper examines the availability and affordability of first-line malaria treatment and diagnostics in the private sector, which is the preferred first point of contact for 61% of households in Uganda between 2007 and 2018. Methods: Cross-sectional surveys were conducted between 2007 and 2018, based on a standardized World Health Organization/Health Action International (WHO/HAI) methodology adapted to assess availability, patient prices, and affordability of ACT medicines in private retail outlets. A minimum of 30 outlets were surveyed per year as prescribed by the standardized methodology co-developed by the WHO and Health Action International. Availability, patient prices, and affordability of malaria rapid diagnostic tests (RDTs) was also tracked from 2012 following the rollout of the test and treat policy in 2010. The median patient prices for the artemisinin-based combinations and RDTs was calculated in US dollars (USD). Affordability was assessed by computing the number of days’ wages the lowest-paid government worker (LPGW) had to pay to purchase a treatment course for acute malaria. Results: Availability of artemether/lumefantrine (A/L), the first-line ACT medicine, increased from 85 to100% in the private sector facilities during the study period. However, there was low availability of diagnostic tests in private sector facilities ranging between 13% (2012) and 37% (2018). There was a large reduction in patient prices for an adult treatment course of A/L from USD 8.8 in 2007 to USD 1.1 in 2018, while the price of diagnostics remained mostly stagnant at USD 0.5. The affordability of ACT medicines and RDTs was below one day’s wages for LPGW. Conclusions: Availability of ACT medicines in the private sector medicines retail outlets increased to 100% while the availability of diagnostics remained low. Although malaria treatment was affordable, the price of diagnostics remained stagnant and increased the cumulative cost of malaria management. Malaria stakeholders should consolidate the gains made and consider the inclusion of diagnostic kits in the subsidy programme

Trends in access to anti‐malarial treatment in the formal private sector in Uganda: an assessment of availability and affordability of first‐line anti‐malarials and diagnostics between 2007 and 2018

Background: Malaria is the single largest cause of illness in Uganda. Since the year 2008, the Global Fund has rolled out several funding streams for malaria control in Uganda. Among these are mechanisms aimed at increasing the availability and affordability of artemisinin-based combination therapy (ACT). This paper examines the availability and affordability of first-line malaria treatment and diagnostics in the private sector, which is the preferred first point of contact for 61% of households in Uganda between 2007 and 2018. Methods: Cross-sectional surveys were conducted between 2007 and 2018, based on a standardized World Health Organization/Health Action International (WHO/HAI) methodology adapted to assess availability, patient prices, and affordability of ACT medicines in private retail outlets. A minimum of 30 outlets were surveyed per year as prescribed by the standardized methodology co-developed by the WHO and Health Action International. Availability, patient prices, and affordability of malaria rapid diagnostic tests (RDTs) was also tracked from 2012 following the rollout of the test and treat policy in 2010. The median patient prices for the artemisinin-based combinations and RDTs was calculated in US dollars (USD). Affordability was assessed by computing the number of days’ wages the lowest-paid government worker (LPGW) had to pay to purchase a treatment course for acute malaria. Results: Availability of artemether/lumefantrine (A/L), the first-line ACT medicine, increased from 85 to100% in the private sector facilities during the study period. However, there was low availability of diagnostic tests in private sector facilities ranging between 13% (2012) and 37% (2018). There was a large reduction in patient prices for an adult treatment course of A/L from USD 8.8 in 2007 to USD 1.1 in 2018, while the price of diagnostics remained mostly stagnant at USD 0.5. The affordability of ACT medicines and RDTs was below one day’s wages for LPGW. Conclusions: Availability of ACT medicines in the private sector medicines retail outlets increased to 100% while the availability of diagnostics remained low. Although malaria treatment was affordable, the price of diagnostics remained stagnant and increased the cumulative cost of malaria management. Malaria stakeholders should consolidate the gains made and consider the inclusion of diagnostic kits in the subsidy programme