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1.  Can Broader Diffusion of Value-Based Insurance Design Increase Benefits from US Health Care without Increasing Costs? Evidence from a Computer Simulation Model 
PLoS Medicine  2010;7(2):e1000234.
Using a computer simulation based on US data, R. Scott Braithwaite and colleagues calculate the benefits of value-based insurance design, in which patients pay less for highly cost-effective services.
Background
Evidence suggests that cost sharing (i.e.,copayments and deductibles) decreases health expenditures but also reduces essential care. Value-based insurance design (VBID) has been proposed to encourage essential care while controlling health expenditures. Our objective was to estimate the impact of broader diffusion of VBID on US health care benefits and costs.
Methods and Findings
We used a published computer simulation of costs and life expectancy gains from US health care to estimate the impact of broader diffusion of VBID. Two scenarios were analyzed: (1) applying VBID solely to pharmacy benefits and (2) applying VBID to both pharmacy benefits and other health care services (e.g., devices). We assumed that cost sharing would be eliminated for high-value services (<$100,000 per life-year), would remain unchanged for intermediate- or unknown-value services ($100,000–$300,000 per life-year or unknown), and would be increased for low-value services (>$300,000 per life-year). All costs are provided in 2003 US dollars. Our simulation estimated that approximately 60% of health expenditures in the US are spent on low-value services, 20% are spent on intermediate-value services, and 20% are spent on high-value services. Correspondingly, the vast majority (80%) of health expenditures would have cost sharing that is impacted by VBID. With prevailing patterns of cost sharing, health care conferred 4.70 life-years at a per-capita annual expenditure of US$5,688. Broader diffusion of VBID to pharmaceuticals increased the benefit conferred by health care by 0.03 to 0.05 additional life-years, without increasing costs and without increasing out-of-pocket payments. Broader diffusion of VBID to other health care services could increase the benefit conferred by health care by 0.24 to 0.44 additional life-years, also without increasing costs and without increasing overall out-of-pocket payments. Among those without health insurance, using cost saving from VBID to subsidize insurance coverage would increase the benefit conferred by health care by 1.21 life-years, a 31% increase.
Conclusion
Broader diffusion of VBID may amplify benefits from US health care without increasing health expenditures.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
More money is spent per person on health care in the US than in any other country. US health care expenditure accounts for 16.2% of the gross domestic product and this figure is rising. Indeed, the increase in health care costs is outstripping the economy's growth rate. Consequently, US policy makers and providers of health insurance—health care in the US is largely provided by the private sector and is paid for through private health insurance or through government programs such as Medicare and Medicaid—are looking for better ways to control health expenditures. Although some health care cost reductions can be achieved by increasing efficiency, controlling the quantity of health care consumed is an essential component of strategies designed to reduce health expenditures. These strategies can target health care providers (for example, by requiring primary care physicians to provide referrals before their patients' insurance provides cover for specialist care) or can target consumers, often through cost sharing. Nowadays, most insurance plans include several tiers of cost sharing in which patients pay a larger proportion of the costs of expensive interventions than of cheap interventions.
Why Was This Study Done?
Cost sharing decreases health expenditure but it can also reduce demand for essential care and thus reduce the quality of care. Consequently, some experts have proposed value-based insurance design (VBID), an approach in which the amount of cost sharing is set according to the “value” of an intervention rather than its cost. The value of an intervention is defined as the ratio of the additional benefits to the additional costs of the intervention when compared to the next best alternative intervention. Under VBID, cost sharing could be waived for office visits necessary to control blood pressure in people with diabetes, which deliver high-value care, but could be increased for high-tech scans for dementia, which deliver low-value care. VBID has been adopted by several private health insurance schemes and its core principal is endorsed by US policy makers. However, it is unclear whether wider use of VBID is warranted. In this study, the researchers use a computer simulation of the US health care system to estimate the impact of broader diffusion of VBID on US health care benefits and costs.
What Did the Researchers Do and Find?
The researchers used their computer simulation to estimate the impact of applying VBID to cost sharing for drugs alone and to cost sharing for drugs, procedures, and other health care services for one million hypothetical US patients. In their simulation, the researchers eliminated cost sharing for services that cost less than US$100,000 per life-year gained (high-value services) and increased cost-sharing for services that cost more than US$300,000 per life-year gained (low-value services); cost-sharing remained unchanged for intermediate- or unknown-value services. With the current pattern of cost sharing, 60% of health expenditure is spent on low-value services and health care increases life expectancy by 4.70 years for an annual per person expenditure of US$5,688, the researchers report. With widespread application of VBID to cost sharing for drugs alone, health care increased life expectancy by an additional 0.03 to 0.05 years without increasing costs. With widespread application of VBID to cost sharing for other health care services, health care increased life expectancy by a further 0.24 to 0.44 years without additional costs. Finally, if the costs saved by applying VBID were used to subsidize insurance for the 15% of the US population currently without health insurance, the benefit conferred by health care among these people would increase by 1.21 life-years.
What Do These Findings Mean?
The findings of this study depend on the many assumptions included in the computer simulation, which, although complex, is a greatly simplified representation of the US health care system. Nevertheless, these findings suggest that if VBID were used more widely within the US health care system to encourage the use of high-value services, it might be possible to amplify the benefits from US health care without increasing health expenditures. Importantly, the money saved by VBID could be used to help fund universal insurance, a central aim of US health care reform. More research is needed, however, to determine the value of various health care interventions and to investigate whether other ways of linking value to cost sharing might yield even better gains in life expectancy at little or no additional cost.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000234.
Wikipedia has a page on health care in the United States (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Families USA works to promote high-quality affordable health care for all Americans and provides information about all aspects of US health care and about US health care reforms
The US Centers for Medicare and Medicaid provides information on the major government health insurance programs and on US national health expenditure statistics
doi:10.1371/journal.pmed.1000234
PMCID: PMC2821897  PMID: 20169114
2.  Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies 
PLoS Medicine  2011;8(4):e1000433.
Paul Garner and colleagues conducted a systematic review of 80 studies to compare the quality of private versus public ambulatory health care in low- and middle-income countries.
Background
In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options.
Methods and Findings
We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred.
Conclusions
Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The provision of private (“for-profit” hospitals and self-employed practitioners, and “not-for-profit” non-government providers, including faith-based organizations) versus public health care services in low and middle income countries raises considerable ideological debate. Ideological arguments aside—which can be very passionate on both sides—there is general agreement that improving the quality of both public and private health care could have a major impact on improved health outcomes, especially as the private sector is so widely used in low and middle income countries. For example, almost three quarters and half of children from the poorest households of South Asia and sub-Saharan Africa, respectively, seek health care from a private provider when they are ill. Private providers are also increasingly responsible for outpatient care for non-communicable diseases.
As a result of the mixed health care system in many low and middle income countries, adequate oversight and stewardship of the mixed system from the national government is essential yet often missing.
Why Was This Study Done?
An understanding of how quality and performance in the private sector compares with that in the public sector would help governments to prioritize where they need to concentrate their efforts. So, for example, if the private sector is generally providing poorer quality care than the public sector, then there is an imperative to improve the quality and outcomes; on the other hand, if the quality of care offered by the private sector is good, the policy priority is to influence the market to further improve access to such health care for low income groups.
In order to help with this comparison, the researchers wanted to systematically identify and summarize the results of studies that directly compared the quality of care offered by public providers with the one offered by “formal” private providers (recognized by law) and “informal” private providers (providers that are not legally recognized, such as lay health workers and shop keepers). For the purposes of this study the researchers focused their comparison on the private and public provision of outpatient care in low and middle income countries.
What Did the Researchers Do and Find?
In their literature review, the researchers searched for relevant studies reported in English, French, or German and published between January 1970 and April 2009. Only studies that compared private and public outpatient medical services in the same country, at the same time, using the same methods, and which met particular quality criteria, were included in the analysis. The researchers also had strict criteria for including qualitative studies, and they retrieved the full text of articles, contacted study authors where appropriate, and verified with a second researcher most (80%) of the extracted study data. In order to evaluate and compare the studies, the researchers converted study values to a linear 100% scale, calculated differences between providers within studies, and summarized the median values of the differences across studies.
The researchers identified a total of 8,812 relevant titles and abstracts and found 80 studies that included direct quantitative comparisons of public and private formal providers. Ten studies included qualitative data. Most studies were conducted after 1990, and mainly in sub-Saharan Africa (n = 39) and Asia and the Pacific (n = 23). Most studies did not report socio-economic status of public and private service users, and only five studies presented data by different income groups. No study compared the same individual providers working in public and private care settings. Only two studies compared public providers and private informal providers, so the authors excluded these from subsequent analysis.
For the formal sector, since the results for “for-profit” and “not-for-profit” providers were similar, the researchers decided to combine the results. Overall, the researchers found that the median values indicated that many services, irrespective of whether public or private, scored low (less than 50%) on infrastructure, clinical competence, and practice. Generally, the private sector performed better in relation to drug supply, responsiveness, and effort, but there was no detectable difference between provider groups for patient satisfaction. Furthermore, a synthesis of qualitative data suggested that the private sector may be more client-centered.
What Do These Findings Mean?
Based on the findings of this review, there is a clear need to consider the quality of primary health services in both the public and private sector in order to improve health outcomes in low and middle income countries. These findings also indicate that, for some aspects of care, on average the private sector provided better quality services. The overall low quality of care in both the formal private and public sector found in this review is worrying, and calls for the governments of low and middle income countries to find and implement effective strategies to improve the quality in both sectors. This is particularly important given the increasing volume of conditions that require relatively sophisticated, long-term ambulatory medical care, such as non-communicable diseases.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000433.
This study is further discussed in a PLoS Medicine Perspective by Jishnu Das
WHO has more information on health service delivery in low- and middle-income countries
WHO has more information on noncommunicable diseases
The World Bank's World Development Report for 2004 addresses health care for poor people
doi:10.1371/journal.pmed.1000433
PMCID: PMC3075233  PMID: 21532746
3.  Evaluating Drug Prices, Availability, Affordability, and Price Components: Implications for Access to Drugs in Malaysia 
PLoS Medicine  2007;4(3):e82.
Background
Malaysia's stable health care system is facing challenges with increasing medicine costs. To investigate these issues a survey was carried out to evaluate medicine prices, availability, affordability, and the structure of price components.
Methods and Findings
The methodology developed by the World Health Organization (WHO) and Health Action International (HAI) was used. Price and availability data for 48 medicines was collected from 20 public sector facilities, 32 private sector retail pharmacies and 20 dispensing doctors in four geographical regions of West Malaysia. Medicine prices were compared with international reference prices (IRPs) to obtain a median price ratio. The daily wage of the lowest paid unskilled government worker was used to gauge the affordability of medicines. Price component data were collected throughout the supply chain, and markups, taxes, and other distribution costs were identified. In private pharmacies, innovator brand (IB) prices were 16 times higher than the IRPs, while generics were 6.6 times higher. In dispensing doctor clinics, the figures were 15 times higher for innovator brands and 7.5 for generics. Dispensing doctors applied high markups of 50%–76% for IBs, and up to 316% for generics. Retail pharmacy markups were also high—25%–38% and 100%–140% for IBs and generics, respectively. In the public sector, where medicines are free, availability was low even for medicines on the National Essential Drugs List. For a month's treatment for peptic ulcer disease and hypertension people have to pay about a week's wages in the private sector.
Conclusions
The free market by definition does not control medicine prices, necessitating price monitoring and control mechanisms. Markups for generic products are greater than for IBs. Reducing the base price without controlling markups may increase profits for retailers and dispensing doctors without reducing the price paid by end users. To increase access and affordability, promotion of generic medicines and improved availability of medicines in the public sector are required.
Drug price and availability data were collected from West Malaysian public sector facilities, private sector retail pharmacies, and dispensing doctors. Mark-ups were higher on generic drugs than on innovator brands.
Editors' Summary
Background.
The World Health Organization has said that one-third of the people of the world cannot access the medicines they need. An important reason for this problem is that prices are often too high for people or government-funded health systems to afford. In developing countries, most people who need medicines have to pay for them out of their own pockets. Where the cost of drugs is covered by health systems, spending on medicines is a major part of the total healthcare budget. Governments use a variety of approaches to try to control the cost of drugs and make sure that essential medicines are affordable and not overpriced. According to the theory of “free market economics,” the costs of goods and services are determined by interactions between buyers and sellers and not by government intervention. However, free market economics does not work well at containing the costs of medicines, particularly new medicines, because new medicines are protected by patent law, which legally prevents others from making, using, or selling the medicine for a particular period of time. Therefore, without government intervention, there is nothing to help to push down prices.
Why Was This Study Done?
Malaysia is a middle-income country with a relatively effective public health system, but it is facing a rapid rise in drug costs. In Malaysia, medicine prices are determined by free-market economics, without any control by government. Government hospitals are expected to provide drugs free, but a substantial proportion of medicines are paid for by patients who buy them directly from private pharmacies or prescribing doctors. There is evidence that Malaysian patients have difficulties accessing the drugs they need and that cost is an important factor. Therefore, the researchers who wrote this paper wanted to examine the cost of different medicines in Malaysia, and their availability and affordability from different sources.
What Did the Researchers Do and Find?
In this research project, 48 drugs were studied, of which 28 were part of a “core list” identified by the World Health Organization as “essential drugs” on the basis of the global burden of disease. The remaining 20 reflected health care needs in Malaysia itself. The costs of each medicine were collected from government hospitals, private pharmacies, and dispensing doctors in four different regions of Malaysia. Data were collected for the “innovator brand” (made by the original patent holder) and for “generic” brands (an equivalent drug to the innovator brand, produced by a different company once the innovator brand no longer has an exclusive patent). The medicine prices were compared against international reference prices (IRP), which are the average prices offered by not-for-profit drug companies to developing countries. Finally, the researchers also compared the cost of the drugs with daily wages, in order to work out their “affordability.”
The researchers found that, irrespective of the source of medicines, prices were on average very much higher than the international reference price, ranging from 2.4 times the IRP for innovator brands accessed through public hospitals, to 16 times the IRP for innovator brands accessed through private pharmacies. The availability of medicines was also very poor, with only 25% of generic medicines available on average through the public sector. The affordability of many of the medicines studied was again very poor. For example, one month's supply of ranitidine (a drug for stomach ulcers) was equivalent to around three days' wages for a low-paid government worker, and one month's supply of fluoxetine (an antidepressant) would cost around 26 days' wages.
What Do These Findings Mean?
These results show that essential drugs are very expensive in Malaysia and are not universally available. Many people would not be able to pay for essential medicines. The cost of medicines in Malaysia seems to be much higher than in areas of India and Sri Lanka, although the researchers did not attempt to collect data in order to carry out an international comparison. It is possible that the high cost and low availability in Malaysia are the result of a lack of government regulation. Overall, the findings suggest that the government should set up mechanisms to prevent drug manufacturers from increasing prices too much and thus ensure greater access to essential medicines.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040082.
Read a related PLoS Medicine Perspective article by Suzanne Hill
Information is available from the World Health Organization on Improving Access to Medicines
Information on medicine prices is available from Health Action International
Wikipedia has an entry on Patent (a type of intellectual property that is normally used to prevent other companies from selling a newly invented medicine). (Wikipedia is an internet encyclopedia anyone can edit.)
The Drugs for Neglected Diseases Initiative is an international collaboration between public organizations that aims to develop drugs for people suffering from neglected diseases
doi:10.1371/journal.pmed.0040082
PMCID: PMC1831730  PMID: 17388660
4.  Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review 
PLoS Medicine  2012;9(6):e1001244.
A systematic review conducted by Sanjay Basu and colleagues reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries.
Introduction
Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.
Methods and Findings
Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.
Conclusions
Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Health care can be provided through public and private providers. Public health care is usually provided by the government through national healthcare systems. Private health care can be provided through “for profit” hospitals and self-employed practitioners, and “not for profit” non-government providers, including faith-based organizations.
There is considerable ideological debate around whether low- and middle-income countries should strengthen public versus private healthcare services, but in reality, most low- and middle-income countries use both types of healthcare provision. Recently, as the global economic recession has put major constraints on government budgets—the major funding source for healthcare expenditures in most countries—disputes between the proponents of private and public systems have escalated, further fuelled by the recommendation of International Monetary Fund (an international finance institution) that countries increase the scope of private sector provision in health care as part of loan conditions to reduce government debt. However, critics of the private health sector believe that public healthcare provision is of most benefit to poor people and is the only way to achieve universal and equitable access to health care.
Why Was This Study Done?
Both sides of the public versus private healthcare debate draw on selected case reports to defend their viewpoints, but there is a widely held view that the private health system is more efficient than the public health system. Therefore, in order to inform policy, there is an urgent need for robust evidence to evaluate the quality and effectiveness of the health care provided through both systems. In this study, the authors reviewed all of the evidence in a systematic way to evaluate available data on public and private sector performance.
What Did the Researchers Do and Find?
The researchers used eight databases and a comprehensive key word search to identify and review appropriate published data and studies of private and public sector performance in low- and middle-income countries. They assessed selected studies against the World Health Organization's six essential themes of health systems—accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency—and conducted a narrative review of each theme.
Out of the 102 relevant studies included in their comparative analysis, 59 studies were research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. The researchers found that study findings varied considerably across countries studied (one-third of studies were conducted in Africa and a third in Southeast Asia) and by the methods used.
Financial barriers to care (such as user fees) were reported for both public and private systems. Although studies report that patients in the private sector experience better timeliness and hospitality, studies suggest that providers in the private sector more frequently violate accepted medical standards and have lower reported efficiency.
What Do These Findings Mean?
This systematic review did not support previous views that private sector delivery of health care in low- and middle-income settings is more efficient, accountable, or effective than public sector delivery. Each system has its strengths and weaknesses, but importantly, in both sectors, there were financial barriers to care, and each had poor accountability and transparency. This systematic review highlights a limited and poor-quality evidence base regarding the comparative performance of the two systems.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001244.
A previous PLoS Medicine study examined the outpatient care provided by the public and private sector in low-income countries
The WHO website provides more information on healthcare systems
The World Bank website provides information on health system financing
Oxfam provides an argument against increased private health care in poor countries
doi:10.1371/journal.pmed.1001244
PMCID: PMC3378609  PMID: 22723748
5.  The effects of ownership and ownership change on nursing home industry costs. 
Health Services Research  1996;31(3):327-346.
OBJECTIVE. This study examines the effects of ownership type and ownership change on nursing home cost structures, differentiating patient care costs from plant costs. DATA SOURCES. Administrative data from the Michigan Department of Social Services, Medical Services Administration (Medicaid), and the Michigan Department of Public Health are used. Cost data are based on audited cost reports for 393 nursing care facilities in Michigan in 1989. Other facility characteristics are based on data from the 1989 annual licensing and certification survey conducted by the Michigan Department of Public Health. STUDY DESIGN. A series of ordinary least squares regressions is estimated, in which the dependent variable is either per diem patient costs or per diem plant costs. Ownership types are defined as chain, proprietary non-chain, freestanding non-profit, government-owned, and hospital-based facilities. Pooled estimation techniques, as well as separate regressions by ownership type, are presented to test for interaction effects. Key variables include whether a facility changed ownership in the preceding five years and whether chain facilities are in-state- or out-of-state-owned, in addition to size, payer mix, and case mix. PRINCIPAL FINDINGS. Behavioral differences among nursing home ownership types in respect to patient care costs tended to distinguish government-owned and hospital-based facilities from the freestanding homes rather than the usual distinction between for-profit and not-for-profit classes. Variables traditionally included in nursing home cost studies, such as size, occupancy, payer mix and case mix, were found to have similar effects on per diem patient care costs for freestanding non-profit homes as well as for chain proprietary facilities. With regard to the effects of ownership change on per diem plant and per diem patient costs, however, there are few differences among ownership types. Chain and non-chain for-profit facilities, non-profit homes, and hospital long-term care units that had changed ownership reported significantly higher per diem plant costs than facilities without a change of ownership, but did not spend more on patient-related costs. Michigan Medicaid plant reimbursement system policy changes instituted in 1985 to promote continued ownership of facilities were not entirely successful. CONCLUSIONS. Non-profit homes look increasingly like their for-profit counterparts with respect to spending on patient care costs. Increased competition for the more lucrative private-pay patients, coupled with declining state Medicaid reimbursement to nursing homes, may have blurred the historical distinctions between the non-profit and for-profit sectors in the nursing home industry. An exception to increasing homogeneity within the nursing home industry is the tendency of proprietary homes to experience more frequent changes of ownership, which results in higher capital costs passed on to state Medicaid programs. Findings from this study indicate that while facility sales increase per diem plant costs, they do not result in increased spending for direct patient care, suggesting that state Medicaid programs may be indirectly subsidizing facility sales with no accompanying increase in expenditures for patient care. To discourage frequent facility sales, state Medicaid programs may need to consider alternative methods of reimbursing nursing home owners for capital costs.
PMCID: PMC1070122  PMID: 8698588
6.  A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis 
PLoS Medicine  2012;9(6):e1001238.
A cost-effective analysis conducted by Edwine Barasa and colleagues estimates that a complex intervention aimed at improving quality of pediatric care would be affordable and cost-effective in Kenya.
Background
To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale.
Methods and Findings
Our cost-effectiveness analysis from the provider's perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26–67.06) in intervention hospitals compared to US$31.1 (95% CI 30.67–47.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19–2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A “what-if” analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3.
Conclusion
Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
According to latest global estimates from UNICEF, 7.6 million children currently die every year before they reach five years of age. Half of these deaths occur in children in sub-Saharan Africa and tragically, most of these deaths are due to a few treatable and preventable diseases, such as pneumonia, malaria, and diarrhea, for which effective interventions are already available. In order to meet the target of the 4th Millennium Development Goal—which aims to reduce the under-five child mortality rate by two-thirds from 1990 levels by 2015—delivering these interventions is essential.
In Kenya, the under-five child mortality rate must be reduced by half from its 2008 level in order to meet the Millennium Development Goal (MDG) target and so improving the management of serious child illness might help achieve this goal. A study published last year in PLoS Medicine described such an approach and included the development and implementation of evidence-based clinical practice guidelines linked to health worker training, follow-up supervision, performance feedback, and facilitation in eight district hospitals in Kenya.
Why Was This Study Done?
In the study mentioned above, the researchers compared the implementation of various processes of care in intervention and control hospitals at baseline and 18 months later and found that performance improved more in the intervention hospitals than in the control hospitals. However, while this strategy was effective at improving the quality of health care, it is unclear whether scaling up the approach would be a good use of limited resources. So in this study, the same researchers performed a cost-effectiveness analysis (which they conducted alongside the original trial) of their quality improvement intervention and estimated the costs and effects of scaling up this approach to cover the entire population of Kenya.
What Did the Researchers Do and Find?
In order to perform the cost part of the analysis, the researchers collected the relevant information on costs by using clinical and accounting record reviews and interviews with those involved in developing and implementing the intervention. The researchers evaluated the effectiveness part of the analysis by comparing the implementation of their improved quality of care strategy as delivered in the intervention hospitals with the partial intervention as delivered in the control hospitals by calculating the mean percentage improvement in the 14 process of care indicators at 18 months. Finally, the researchers calculated the costs of scaling up the intervention by applying their results to the whole of Kenya—121 hospital facilities with an estimated annual child admission rate of 2,000 per facility.
The researchers found that the quality of care (as measured by the process of care indicators) was 25% higher in intervention hospitals than in control hospitals, while the cost per child admission was US$50.74 in intervention hospitals compared to US$31.1 in control hospitals. The researchers calculated that each percentage improvement in the average quality of care was achieved at an additional cost of US$0.79 per admitted child. Extrapolating these results to all of Kenya, the estimated annual cost of scaling up the intervention nationally was US$3.6 million, about 0.6% of the annual child health budget in Kenya.
What Do These Findings Mean?
The findings of this cost-effectiveness analysis suggests that a comprehensive quality improvement intervention is effective at improving standards of care but at an additional cost, which may be relatively cost effective compared with basic care if the improvements observed are associated with decreases in child inpatient mortality. The absolute costs for scaling up are comparable to, or even lower than, costs of other, major child health interventions. As the international community is giving an increasing focus to strengthening health systems, these findings provide a strong case for scaling up this intervention, which improves quality of care and service provision for the major causes of child mortality, in rural hospitals throughout Kenya and other district hospitals in sub-Saharan Africa.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001238.
The researchers' original article appeared in PLoS Medicine in 2011: Ayieko P, Ntoburi S, Wagai J, Opondo C, Opiyo N, et al. (2011) A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial. PLoS Med 8(4): e1001018. doi:10.1371/journal.pmed.1001018
The IDOC Africa provides further information on the ETAT+ strategy
The World Health Organization (WHO) provides information on MDG 4, including strategies to reduce global child mortality) and the WHO pocket-book “Hospital care for children” includes guidelines for the management of common but serious childhood illnesses in resource-limited settings
UNICEF www.unicef.org also publishes information on global child mortality rates and the Countdown to 2015 website tracks coverage levels for health interventions proven to reduce child mortality
doi:10.1371/journal.pmed.1001238
PMCID: PMC3373608  PMID: 22719233
7.  Access to artemisinin-based combination therapy (ACT) and quinine in malaria holoendemic regions of western Kenya 
Malaria Journal  2014;13:290.
Background
Artemisinin-based combination therapy (ACT) has been adopted as the most effective treatment against malaria in many endemic countries like Kenya while quinine has remained the second line. The objective of the current study was to assess access to Kenya’s policy recommended anti-malarials, ACT and quinine in the public, private and not-for-profit drug outlets in western Kenya.
Methods
A cross-sectional survey using purposive sampling of 288 outlets (126 public, 96 private, 66 not-for-profit) was conducted in western Kenya in two regions with varying Plasmodium falciparum endemicities. Information on access (availability, price, affordability) on ACT and quinine was collected using the WHO and Healthcare Associated Infection (HAI) standardized methodologies for availability, prices and affordability of drugs. From a Ministry of Health database, the following were included in the analyses: one (1) main public hospital, followed by random selection of five hospitals under this main facility. Eight other public outlets under each of the hospitals were selected, to a total of 96. Matching number of private outlets (n = 96), all (66) not-for-profit outlets and additional 30 public health facilities were sampled to get the required sample size of 288.
Results
More public 111 (88.1%) and not-for-profit 27 (40.9%) outlets stocked subsidized ACT (artemether-lumefantrine, AL). Other artemisinin-based combinations were widely available for both children 93 (96.9%) and adults 82 (85.0%) in private outlets. Frequent stock-outs were in public in 106 (84%), reporting three times or more stock-outs in three months. Subsidized ACT (AL) was sold at median price of USD 0.94 and 0.75 in private and not-for-profit outlets respectively. The costs was higher than recommended price of USD 0.5 and requiring up to 0.20-0.25 days of disposable income for households in lowest economic status.
Conclusion
There is low availability of subsidized ACT (AL) and higher frequency of stock-outs in government facilities, while private sector sells AL at higher prices, thus making it less affordable to many households. These factors determine the adherence to the dosing schedules during the treatment course and thus the evaluation of the subsidy policy, its implementation and role in malaria burden in this region is compulsory.
doi:10.1186/1475-2875-13-290
PMCID: PMC4120722  PMID: 25066600
8.  Creating spatially defined databases for equitable health service planning in low-income countries: the example of Kenya 
Acta tropica  2004;91(3):239-251.
Equity is an important criterion in evaluating health system performance. Developing a framework for equitable and effective resource allocation for health depends upon knowledge of service providers and their location in relation to the population they should serve. The last available map of health service providers in Kenya was developed in 1959. We have built a health service provider database from a variety of traditional government and opportunistic non-government sources and positioned spatially these facilities using global positioning systems, hand-drawn maps, topographical maps and other sources. Of 6674 identified service providers 3355 (50%) were private sector, employer-provided or specialist facilities and only 39% were registered in the Kenyan Ministry of Health database during 2001. Of 3319 public service facilities supported by the Ministry of Health, missions, not-for-profit organizations and local authorities, 84% were registered on a Ministry of Health database and we were able to acquire co-ordinates for 92% of these. The ratio of public health services to population changed from 1:26,000 in 1959 to 1:9,300 in 1999-2002.
There were 82% of the population within 5km of a public health facility and resident in 20% of the country. Our efforts to recreate a comprehensive, spatially defined list of health service providers has identified a number of weaknesses in existing national health management information systems which with an increased commitment and minimal costs can be redressed. This will enable geographic information systems to exploit more fully facility-based morbidity data, population distribution and health access models to target resources and monitor the ability of health sector reforms to achieve equity in service provision.
doi:10.1016/j.actatropica.2004.05.003
PMCID: PMC2673552  PMID: 15246930
health management information systems; geographic information systems; health reform; health resource allocation; equity; access; health services; Kenya
9.  Analysis of the ‘reformpool’-activity in Austria: is the challenge met? 
Aim
The purpose of our study is to analyse the activities initiated by the foundation of the reformpools on the regional level. We wanted to see not only what projects have emerged from these funds, but also how the incentives of this special way of funding influence the activity and what overall impact can be expected on health services delivery in the future.
Context
In Austria, all expenses in the outpatient sector are borne by the statutory health insurance. But in the inpatient sector, SHI just co-finances about 45% of all costs incurred by patients, with the rest contributed by the federal, regional and municipal level. This, however, leads to a number of problems in today's epidemiological situation with patients in need of many different interventions in the course of their chronic disease.
Originally with the aim of finding solutions to these interface problems between inpatient and outpatient care, the healthcare reform 2005 instated the instrument of the reformpool. The reformpool unites funds from social health insurance and regions to finance projects that develop new ways of health services delivery across the sectors. In the course of recent reforms, it became explicitly possible to sponsor projects of integrated care, which had de facto already been the case before.
Theory
The reform pool has various disincentives or wrong incentives compared to e.g. the German ‘Anschubfinanzierung’ for IC-contracts, which was probably a role-model for the Austrian reformpool, because of the underlying differences in the healthcare system and the distinct differences in the regulation. For example, the ‘Anschubfinanzierung’ in Germany withdraws money from the available funds for contract physicians to finance IC-projects, whereas in Austria, their fees are fixed. So in Austria, there is no incentive to retrieve money by participating in such projects. For the stakeholders supplying the pool, mainly the sickness funds and the regions, many projects inflict additional costs on the one or on the other in the future. So as both parties have to agree on projects, there is a strong basic disincentive to grant funds in the present. If a project is in both their interest because it is reducing costs, the care providers might not be interested to participate, as this would diminish their revenues in the future. What is more, the federal control over the (region-based) funds and projects is poor, which might lead to duplication of efforts and missing scale-efficiency in some regions.
Methods and data
For our analysis, we conducted a survey with a standardised questionnaire sent to the management of the regional health funds, which are responsible for the reformpool funds. The questionnaire was checked by experts of the federal association of social security institutions. We also conducted an on-site visit of the reformpool-manager, a programme which can be used to evaluate the reformpool-projects. In addition, we used all available evaluation reports of projects to assess the situation of evaluation of the projects. Furthermore, we used financial data from the regional health funds, the federal association of social security institutions, from the ministry of health and the regional health funds to assess the usage of the reformpool.
(Preliminary) Results
The qualitative results are mixed. Some projects are promising with regard to improvements of the current situation and are well evaluated. Many projects neglect the requirement of the reformpool to be such as to yield a monetary benefit for the system but only focus on improving service delivery. Some evaluations are not well operationalised and thus, arguments why these projects should be transformed to ordinarily financed services will be lacking. The reformpool activity set on very slowly, with only one project already started in 2005, the first possible year. In 2007 we see the highest number (23) of new projects granted and the highest monetary volume, €11 Mio total for 21 of them 1, with activity subsiding in 2008 (6 projects with a volume of € 2.5 Mio total for 5 of them 1) and most certainly in 2009 (with diminishing tax revenues and health insurance contributions) with only one project granted in the first quarter of the year. Of all funds (theoretically) available, only about 16% have been put to use in a reformpool project per year, with high variation (e.g. in the region of Styria over 30%, in Tyrol only 1.5%).
(Preliminary) Conclusions
From our study we can tell that the instrument of reformpool was not devised well concerning its incentive structure, and the interest to conduct such projects is diminishing. Stricter control of the requirements by the federal level, more pronounced requirements, a dedication of the funds to projects instead of a virtual budget and more cooperation between regions could improve the effectiveness of the instrument. Conflicts of interest: The project was funded by the federal association of social security institutions. All authors are researchers at the IHS and hold no commercial interests in the subject. Additional information: Founded by the economist Oskar Morgenstern and the sociologist Paul Lazarsfeld, the IHS (Institute for Advanced Studies) is a non-profit post-graduate teaching and research facility in the fields of economics, sociology and politology, and one of the two Austrian institutes preparing the official economic forecast for Austria. For more than a decade, it has been one of the major research facilities in the fields of health economics and health policy in Austria.
PMCID: PMC2807071
evidence-based guidelines; quality of care
10.  Cost recovery of NGO primary health care facilities: a case study in Bangladesh 
Background
Little is known about the cost recovery of primary health care facilities in Bangladesh. This study estimated the cost recovery of a primary health care facility run by Building Resources Across Community (BRAC), a large NGO in Bangladesh, for the period of July 2004 - June 2005. This health facility is one of the seven upgraded BRAC facilities providing emergency obstetric care and is typical of the government and private primary health care facilities in Bangladesh. Given the current maternal and child mortality in Bangladesh and the challenges to addressing health-related Millennium Development Goal (MDG) targets the financial sustainability of such facilities is crucial.
Methods
The study was designed as a case study covering a single facility. The methodology was based on the 'ingredient approach' using the allocation techniques by inpatient and outpatient services. Cost recovery of the facility was estimated from the provider's perspective. The value of capital items was annualized using 5% discount rate and its market price of 2004 (replacement value). Sensitivity analysis was done using 3% discount rate.
Results
The cost recovery ratio of the BRAC primary care facility was 59%, and if excluding all capital costs, it increased to 72%. Of the total costs, 32% was for personnel while drugs absorbed 18%. Capital items were17% of total costs while operational cost absorbed 12%. Three-quarters of the total cost was variable costs. Inpatient services contributed 74% of total revenue in exchange of 10% of total utilization. An average cost per patient was US$ 10 while it was US$ 67 for inpatient and US$ 4 for outpatient.
Conclusion
The cost recovery of this NGO primary care facility is important for increasing its financial sustainability and decreasing donor dependency, and achieving universal health coverage in a developing country setting. However, for improving the cost recovery of the health facility, it needs to increase utilization, efficient planning, resource allocation and their optimum use. It also requires controlling variable costs and preventing any wastage of resources.
doi:10.1186/1478-7547-8-12
PMCID: PMC3782740  PMID: 20529379
11.  Clinical Benefits, Costs, and Cost-Effectiveness of Neonatal Intensive Care in Mexico 
PLoS Medicine  2010;7(12):e1000379.
Joshua Salomon and colleagues performed a cost-effectiveness analysis using health and economic outcomes following preterm birth in Mexico and showed that neonatal intensive care provided high value for the money in this setting.
Background
Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico.
Methods and Findings
A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24–26, 27–29, and 30–33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24–26, 27–29, and 30–33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses.
Conclusions
Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Most pregnancies last about 40 weeks but increasing numbers of babies are being born preterm, before they reach 37 weeks of gestation (the period during which a baby develops in its mother). In developed countries and some middle-income countries such as Mexico, improvements in the care of newborn babies (neonatal intensive care) mean that more preterm babies survive now than in the past. Nevertheless, preterm birth is still a major cause of infant death worldwide that challenges attainment of Target 5 of Millennium Development Goal 4—the reduction of the global under-five mortality rate by two-thirds of the 1990 rate by 2015 (the Millennium Development Goals, which were agreed by world leaders in 2000, aim to reduce world poverty). Furthermore, many preterm babies who survive have long-term health problems and disabilities such as cerebral palsy, deafness, or learning difficulties. The severity of these disabilities and their long-term costs to families and to society depend on the baby's degree of prematurity.
Why Was This Study Done?
Mexico recently reformed its health system in an effort to improve access to care, particularly for the poorest sections of its population, and to improve the quality of its health care. The central component of this health care reform is the System of Social Protection of Health (SSPH). The SSPH contains a family health insurance program—Seguro Popular—that aims to provide the 50 million uninsured people living in Mexico with free access to an explicit set of health care interventions. As with any insurance program, decisions have to be made about which interventions Seguro Poplar should cover. Should neonatal intensive care be covered, for example? Do the benefits of this intervention (increased survival of babies) outweigh the costs of neonatal care and of long-term care for survivors with disabilities? In other words, is neonatal intensive care cost-effective? In this study, the researchers investigate this question by estimating the clinical benefits, costs, and cost-effectiveness of neonatal intensive care in Mexico.
What Did the Researchers Do and Find?
The researchers built a decision analytic model, a mathematical model that combines evidence on the outcomes and costs of alternative treatments to help inform decisions about health care policy. They gathered data about the health outcomes of preterm births in Mexico from registers of births and deaths and from hospital discharge databases, and estimated the costs of neonatal intensive care and long-term care for disabled survivors using data from the Mexican Ministry of Health and the World Health Organization. They then applied their model, which estimates changes in parameters such as life expectancy, lifetime costs, disability-adjusted life years (DALYs; one DALY represents the loss of a year of healthy life), and incremental cost-effectiveness ratios (ICERs; the additional cost expended for each DALY averted) for neonatal intensive care compared to no intensive care, to a group of 2 million infants. Neonatal intensive care for infants born at 24–26, 27–29, and 30–33 weeks gestation prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs at incremental costs of US$11,000, US$10,000, and US$3000, respectively, compared to no intensive care. The ICERs of neonatal intensive care for babies born at these times were US$1200, US$700, and US$300 per DALY averted, respectively.
What Do These Findings Mean?
Interventions with ICERs of less than a country's per capita gross domestic product (GDP) are highly cost-effective; those with ICERs of 1–3 times the per capita GDP are potentially cost-effective. Mexico's per capita GDP in 2005 was approximately US$8,200. Thus, neonatal intensive care could provide exceptional value for money in Mexico (and maybe in other middle-income countries), even for very premature babies. The accuracy of these findings inevitably depends on the assumptions used to build the decision analytic model and on the accuracy of the data fed into it, but the findings were little changed by a wide range of alterations that the researchers made to the model. Importantly, however, this cost-effectiveness analysis focuses on health and economic consequences of different intervention choices, and does not capture all aspects of well-being. Decisions regarding neonatal intensive care will need to be based on a full consideration of all relevant factors, including ethical issues, and cost-effectiveness analyses should continue to be updated as new data emerge on health outcomes and costs associated with neonatal intensive care.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000379.
The March of Dimes, a nonprofit organization for pregnancy and baby health, provides information on preterm birth (in English and Spanish)
The Nemours Foundation, another nonprofit organization for child health, also provides information on premature babies (in English and Spanish)
MedlinePlus provides links to other information on premature babies (in English and Spanish)
The United Nations Childrens Fund (UNICEF) works for children's rights, survival, development and protection around the world; it provides information on Millennium Development Goal 4 and its Childinfo website provides detailed statistics about child survival and health (some information in several languages)
A PLoS Medicine Policy Forum by Núria Homedes and Antonio Ugalde discusses health care reforms in Mexico
doi:10.1371/journal.pmed.1000379
PMCID: PMC3001895  PMID: 21179496
12.  Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years' Evaluation in Afghanistan 
PLoS Medicine  2011;8(7):e1001066.
Anbrasi Edward and colleagues report the results of a balanced scorecard performance system used to examine 29 key performance indicators over a 5-year period in Afghanistan, between 2004 and 2008.
Background
In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008.
Methods and Findings
Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0–100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3–84.5, p<0.0001); provider satisfaction (65.4–79.2, p<0.01); capacity for service provision (47.4–76.4, p<0.0001); quality of services (40.5–67.4, p<0.0001); and overall vision for pro-poor and pro-female health services (52.0–52.6). The financial domain also showed improvement until 2007 (84.4–95.7, p<0.01), after which user fees were eliminated. By 2008, all provinces achieved the upper benchmark of national median set in 2004.
Conclusions
The BSC has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period. However, scorecard reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture to ensure its continued relevance and effectiveness as a comprehensive health system performance measure. The process of BSC design and implementation can serve as a valuable prototype for health policy planners managing performance in similar health care contexts.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Traditionally, the performance of a health system (the complete network of health care agencies, facilities, and providers in a defined geographical region) has been measured in terms of health outcomes: how many people have been treated, how many got better, and how many died. But, nowadays, with increased demand for improved governance and accountability, policy makers are seeking comprehensive performance measures that show in detail how innovations designed to strengthen health systems are affecting service delivery and health outcomes. One such performance measure is the “balanced scorecard,” an integrated management and measurement tool that enables organizations to clarify their vision and strategy and translate them into action. The balanced scorecard—essentially a list of key performance indicators and performance benchmarks in several domains—was originally developed for industry but is now becoming a popular strategic management tool in the health sector. For example, balanced scorecards have been successfully integrated into the Dutch and Italian public health care systems.
Why Was This Study Done?
Little is known about the use of balanced scorecards in the national public health care systems of developing countries but the introduction of performance management into health system reform in fragile states in particular (developing countries where the state fails to perform the fundamental functions necessary to meet its citizens' basic needs and expectations) could help to promote governance and leadership, and facilitate essential policy changes. One fragile state that has introduced the balanced scorecard system for public health care management is Afghanistan, which emerged from decades of conflict in 2002 with some of the world's worst health indicators. To deal with an extremely high burden of disease, the Ministry of Public Health (MOPH) designed a Basic Package of Health Services (BPHS), which is delivered by nongovernmental organizations and MOPH agencies. In 2004, the MOPH introduced the National Health Service Performance Assessment (NHSPA), an annual country-wide assessment of service provision and patient satisfaction and pioneered a balanced scorecard, which uses data collected in the NHSPA, to manage the delivery of primary health care services. In this study, the researchers examine the trends between 2004 and 2008 of the 29 key performance indicators in six domains included in this balanced scorecard, and consider the potential and limitations of the scorecard as a management tool to measure and improve health service delivery in Afghanistan and other similar countries.
What Did the Researchers Do and Find?
Each year of the study, a random sample of 25 facilities (district hospitals and comprehensive and basic health centers) in 28 of Afghanistan's 34 provinces was chosen (one province did not have functional facilities in 2004 and the other five missing provinces were inaccessible because of ongoing conflicts). NHSPA surveyors collected approximately 5,000 patient observations, 5,000 exit interviews with patients or their caregivers, and 1,500 health provider interviews by observing consultations involving five children under 5 years old and five patients over 5 years old in each facility. The researchers then used this information to evaluate the key performance indicators in the balanced scorecard and a statistical method called generalized estimating equation modeling to assess trends in these indicators. They report that there was a progressive improvement in national average scores in all six domains (patients and community satisfaction with services, provider satisfaction, capacity for service provision, quality of services, overall vision for pro-poor and pro-female health services, and financial systems) between 2004 and 2008.
What Do These Findings Mean?
These findings suggest that the balanced scorecard was successfully used to improve health system capacity and service delivery through performance benchmarking over the 5-year study period. Importantly, the use of the balanced scorecard helped to show the effects of investments, facilitate policy change, and create a more evidence-based decision-making culture in Afghanistan's primary health care system. However, the researchers warn that the continuing success of the balanced scorecard in Afghanistan will depend on its ability to accommodate changes in health systems policy. Furthermore, reconfigurations of the scorecard are needed to include measures of the overall effectiveness and efficiency of the health system such as mortality rates. More generally, the researchers conclude that the balanced scorecard offers a promising measure of health system performance that could be used to examine the effectiveness of health care strategies and innovations in other fragile and developing countries.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001066.
A 2010 article entitled An Afghan Success Story: The Balanced Scorecard and Improved Health Services in The Globe, a newsletter produced by the Department of International Health at the John Hopkins Bloomberg School of Public Health, provides a detailed description of the balanced scorecard used in this study
Wikipedia has a page on health systems and on balanced scorecards (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Health Organization country profile of Afghanistan provides information on the country's health system and burden of disease (in several languages)
doi:10.1371/journal.pmed.1001066
PMCID: PMC3144209  PMID: 21814499
13.  Increasing Coverage and Decreasing Inequity in Insecticide-Treated Bed Net Use among Rural Kenyan Children 
PLoS Medicine  2007;4(8):e255.
Background
Inexpensive and efficacious interventions that avert childhood deaths in sub-Saharan Africa have failed to reach effective coverage, especially among the poorest rural sectors. One particular example is insecticide-treated bed nets (ITNs). In this study, we present repeat observations of ITN coverage among rural Kenyan homesteads exposed at different times to a range of delivery models, and assess changes in coverage across socioeconomic groups.
Methods and Findings
We undertook a study of annual changes in ITN coverage among a cohort of 3,700 children aged 0–4 y in four districts of Kenya (Bondo, Greater Kisii, Kwale, and Makueni) annually between 2004 and 2006. Cross-sectional surveys of ITN coverage were undertaken coincidentally with the incremental availability of commercial sector nets (2004), the introduction of heavily subsidized nets through clinics (2005), and the introduction of free mass distributed ITNs (2006). The changing prevalence of ITN coverage was examined with special reference to the degree of equity in each delivery approach. ITN coverage was only 7.1% in 2004 when the predominant source of nets was the commercial retail sector. By the end of 2005, following the expansion of heavily subsidized clinic distribution system, ITN coverage rose to 23.5%. In 2006 a large-scale mass distribution of ITNs was mounted providing nets free of charge to children, resulting in a dramatic increase in ITN coverage to 67.3%. With each subsequent survey socioeconomic inequity in net coverage sequentially decreased: 2004 (most poor [2.9%] versus least poor [15.6%]; concentration index 0.281); 2005 (most poor [17.5%] versus least poor [37.9%]; concentration index 0.131), and 2006 with near-perfect equality (most poor [66.3%] versus least poor [66.6%]; concentration index 0.000). The free mass distribution method achieved highest coverage among the poorest children, the highly subsidised clinic nets programme was marginally in favour of the least poor, and the commercial social marketing favoured the least poor.
Conclusions
Rapid scaling up of ITN coverage among Africa's poorest rural children can be achieved through mass distribution campaigns. These efforts must form an important adjunct to regular, routine access to ITNs through clinics, and each complimentary approach should aim to make this intervention free to clients to ensure equitable access among those least able to afford even the cost of a heavily subsidized net.
Noor and colleagues found low levels of use of insecticide-treated mosquito nets when nets were mainly available through the commercial sector. Levels increased when subsidized nets were introduced and rose further when they were made available free.
Editors' Summary
Background.
Malaria is one of the world's most important killer diseases. There are over a million deaths from malaria every year, most of those who die are children in Africa. Frequent attacks of the disease have severe consequences for the health of many millions more. The parasite that causes malaria is spread by bites from certain species of mosquito. They mostly bite during the hours of darkness, so sleeping under a mosquito net provides some protection. In some countries where malaria is a problem, bed nets are already used by many people. A very much higher level of protection is obtained, however, by sleeping under a mosquito net that has been impregnated with insecticide. The insecticides used are of extremely low toxicity for humans. As insecticide-treated nets (ITNs) are a relatively new idea, people do need to be persuaded to buy and use them. ITNs must also be re-impregnated regularly, although long-lasting ones that remain effective for 3–5 y (or 21 washes) are now widely distributed. The nets are inexpensive by Western standards but the people who are most at risk of malaria have very little income. Governments and health agencies are keen to increase the use of nets, particularly for children and pregnant women. The main approach used has been that of “social marketing.” In other words, advertising campaigns promote the use of nets, and their local manufacture is encouraged. The nets are then sold on the open market, sometimes with government subsidies. This approach has been very controversial. Many people have argued that ways must be found to make nets available free to all who need them, but others believe that this is not necessary and that high rates of ITN use can be brought about by social marketing alone.
Why Was This Study Done?
It has been known for more than ten years that ITNs are very effective in reducing cases of malaria, but there is still a long way to go before every child at risk sleeps under an ITN. In Kenya, a country where malaria is very common, a program to increase net use began in 2002, using the social marketing approach. In 2004 most of the nets available in Kenya were those on sale commercially. In October 2004 health clinics started to distribute more heavily subsidized ITNs for children and pregnant women and, in 2006, a mass distribution program began of free nets for children. The researchers, based at the Kenya Medical Research Institute (KEMRI), wanted to find whether the number of children sleeping under ITNs changed as a result of these changes in policy. They also wanted to see how the rate of net use varied between families of different socioeconomic levels, as the poorest children are known to be most likely to die from malaria.
What Did the Researchers Do and Find?
This is a large study involving 3,700 children in four districts of Kenya. The researchers conducted surveys and then calculated the rates of net use in 2004, 2005, and 2006. In the first survey, when nets were available to most people only through the commercial sector, only 7% of children were sleeping under ITNs, with a very big difference between the poorest families (3%) and the least poor (16%). By the end of 2005, the year in which subsidized nets became increasingly available in clinics, the overall rate of use rose to 24%. By the end of 2006, following the free distribution campaign, it was 66%. The 2006 figure was almost exactly the same for the poorest and least poor families.
What Do These Findings Mean?
The rate of net use in the districts in the survey is much higher than expected, even though one-third of children were still not protected by ITNs. The sharp increases—particularly among the poorest children—after heavily subsidized nets were introduced and then after the free mass distribution suggests that this is a very good use of the limited amount of funds available for health care in Kenya and other countries where malaria is common. If fewer Kenyan children have malaria there will be cost savings to the health services. While some might claim that it is obvious that nets will be more widely used if they are free, there has been heated debate as to whether this is really true. Evidence has been needed and this research now provides strong support for free distribution. The study has also identified other factors which will be important in the continuing efforts to increase ITN use.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040255.
The US Centers for Disease Control and Prevention provide information on malaria and on insecticide-treated nets (in English and Spanish)
The MedlinePlus encyclopedia contains a page on malaria (in English and Spanish). MedlinePlus brings together authoritative information from the US National Library of Medicine, National Institutes of Health, and other government agencies and health-related organizations
Information is available from the World Health Organization on malaria (in English, Spanish, French, Russian, Arabic, and Chinese) and from the Roll Back Malaria Partnership on the use of insecticide-treated nets
For information about the Medical Research Institute see the organization's Web site
The BBC Web site has a “country profile” about Kenya
Malaria data and related publications can be found on the Malaria Atlas Project Web site, which is funded by the Wellcome Trust, UK and is a joint project between the Malaria Public Health & Epidemiology Group, Centre for Geographic Medicine, Kenya and the Spatial Ecology & Epidemiology Group, University of Oxford, UK
The Kenya Ministry of Health, Division of Malaria Control Web site has useful information on malaria epidemiology and policies for Kenya
doi:10.1371/journal.pmed.0040255
PMCID: PMC1949846  PMID: 17713981
14.  Early and Late Direct Costs in a Southern African Antiretroviral Treatment Programme: A Retrospective Cohort Analysis 
PLoS Medicine  2009;6(12):e1000189.
Gary Maartens and colleagues describe the direct heath care costs and identify the drivers of cost over time in an HIV managed care program in Southern Africa.
Background
There is a paucity of data on the health care costs of antiretroviral therapy (ART) programmes in Africa. Our objectives were to describe the direct heath care costs and establish the cost drivers over time in an HIV managed care programme in Southern Africa.
Methods/Findings
We analysed the direct costs of treating HIV-infected adults enrolled in the managed care programme from 3 years before starting non-nucleoside reverse transcriptase inhibitor-based ART up to 5 years afterwards. The CD4 cell count criterion for starting ART was <350 cells/µl. We explored associations between variables and mean total costs over time using a generalised linear model with a log-link function and a gamma distribution. Our cohort consisted of 10,735 patients (59.4% women) with 594,497 mo of follow up data (50.9% of months on ART). Median baseline CD4+ cell count and viral load were 125 cells/µl and 5.16 log10 copies/ml respectively. There was a peak in costs in the period around ART initiation (from 4 mo before until 4 mo after starting ART) driven largely by hospitalisation, following which costs plateaued for 5 years. The variables associated with changes in mean total costs varied with time. Key early associations with higher costs were low baseline CD4+ cell count, high baseline HIV viral load, and shorter duration in HIV care prior to starting ART; whilst later associations with higher costs were lower ART adherence, switching to protease inhibitor-based ART, and starting ART at an older age.
Conclusions
Drivers of mean total costs changed considerably over time. Starting ART at higher CD4 counts or longer pre-ART care should reduce early costs. Monitoring ART adherence and interventions to improve it should reduce later costs. Cost models of ART should take into account these time-dependent cost drivers, and include costs before starting ART.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
About 30 million people (22 million people in sub-Saharan Africa alone) are infected with the human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS). HIV destroys immune system cells (including CD4 cells, a type of lymphocyte), leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, on average HIV-positive people died within 10 years of infection. Then, in 1996, highly active antiretroviral therapy (ART; combinations of powerful antiretroviral drugs) was developed. For people living in affluent, developed countries HIV/AIDS became a chronic, treatable condition, but for the millions of HIV-infected people living in low- and middle-income countries, effective treatment was unavailable and HIV/AIDS remained a fatal illness. In 2003, this situation was declared a global health emergency and governments, international agencies, and funding bodies began to implement plans to increase ART coverage in developing countries. By the end of 2008, of the 9.5 million people in need of ART in low- and middle-income countries, more than 4 million people were receiving treatment.
Why Was This Study Done?
Good progress is being made towards achieving universal access to ART, partly because the cost of antiretroviral drugs has plummeted in developing countries. But the provision of antiretroviral drugs is not the only direct cost associated with ART. General practitioner, specialist, and maternity-related care for patients receiving ART, hospital accommodation when necessary, and the investigations that are needed to monitor the progress of HIV infection such as CD4 cell counts and viral load measurements all incur considerable costs. To use their limited resources effectively, public-health officials in developing countries need to know as much as possible about the direct costs of HIV health care but few studies have investigated these costs, particularly those incurred before an individual starts taking ART. In this study, the researchers explore health care costs in a South African private-sector HIV/AIDS program and examine the variables that drive the costs of HIV health care around the time of ART initiation and during later phases of ART.
What Did the Researchers Do and Find?
The researchers analyzed the direct costs of treating more than 100,000 HIV-infected adults enrolled in a private HIV care program in South Africa from 3 years before they started ART until up to 5 years after ART initiation; within this program, individuals began to receive ART when their CD4 cell count fell below 350 cells/µl of blood. The researchers found a peak in direct health costs from 4 months before to 4 months after starting ART (the “peri-ART” period), which was driven mainly by hospital costs. After the peri-ART period, costs dropped (although not to the levels seen before this period) and stabilized at an intermediate level for the next 5 years. Detailed statistical analyses suggest that the key variables associated with higher costs in the peri-ART period were a low baseline CD4 cell count, a high baseline HIV viral load, and a shorter time in HIV care before ART initiation. The key variable associated with higher costs later in ART was lower adherence to the drug therapy. That is, costs were higher among patients who did not take their antiretroviral drugs regularly.
What Do These Findings Mean?
This study involved patients enrolled in a private health care program in which the criteria for initiating ART differed somewhat from those recommended by the World Health Organization for ART initiation in resource-limited settings. Thus, the absolute mean total costs calculated by the researchers are unlikely to be generalizable to public HIV care systems in South Africa and in other resource-poor settings. However, the finding that the drivers of mean total costs change considerably over time may be generalizable and provides some useful information for public-health planners that can now be tested in other, more resource-limited patient populations. In particular, the findings of this study suggest that the high early costs of ART programs could be reduced by starting ART at higher CD4 cell counts or by providing longer pre-ART care. In addition, the findings suggest that monitoring ART adherence and introducing interventions to improve ART adherence could reduce the later direct costs of ART programs.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000189.
Information is available from the US National Institute of Allergy and infectious diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on the HIV and AIDS in Africa, and on universal access to AIDS treatment (in English and Spanish)
The World Health Organization provides information about universal access to AIDS treatment, including the September 2009 progress report (in English and French)
The US Centers for Disease Control and Prevention also provides information on global efforts to deal with the HIV/AIDS epidemic
doi:10.1371/journal.pmed.1000189
PMCID: PMC2777319  PMID: 19956658
15.  Oral Health Care Reform in Finland – aiming to reduce inequity in care provision 
BMC Oral Health  2008;8:3.
Background
In Finland, dental services are provided by a public (PDS) and a private sector. In the past, children, young adults and special needs groups were entitled to care and treatment from the public dental services (PDS). A major reform in 2001 – 2002 opened the PDS and extended subsidies for private dental services to all adults. It aimed to increase equity by improving adults' access to oral health care and reducing cost barriers. The aim of this study was to assess the impacts of the reform on the utilization of publicly funded and private dental services, numbers and distribution of personnel and costs in 2000 and in 2004, before and after the oral health care reform. An evaluation was made of how the health political goals of the reform: integrating oral health care into general health care, improving adults' access to care and lowering cost barriers had been fulfilled during the study period.
Methods
National registers were used as data sources for the study. Use of dental services, personnel resources and costs in 2000 (before the reform) and in 2004 (after the reform) were compared.
Results
In 2000, when access to publicly subsidised dental services was restricted to those born in 1956 or later, every third adult used the PDS or subsidised private services. By 2004, when subsidies had been extended to the whole adult population, this increased to almost every second adult. The PDS reported having seen 118 076 more adult patients in 2004 than in 2000. The private sector had the same number of patients but 542 656 of them had not previously been entitled to partial reimbursement of fees.
The use of both public and subsidised private services increased most in big cities and urban municipalities where access to the PDS had been poor and the number of private practitioners was high. The PDS employed more dentists (6.5%) and the number of private practitioners fell by 6.9%. The total dental care expenditure (PDS plus private) increased by 21% during the study period. Private patients who had previously not been entitled to reimbursements seemed to gain most from the reform.
Conclusion
The results of this study indicate that implementation of a substantial reform, that changes the traditionally defined tasks of the public and private sectors in an established oral health care provision system, proceeds slowly, is expensive and probably requires more stringent steering than was the case in Finland 2001 – 2004. However, the equity and fairness of the oral health care provision system improved and access to services and cost-sharing improved slightly.
doi:10.1186/1472-6831-8-3
PMCID: PMC2268684  PMID: 18226197
16.  Incremental cost of increasing access to maternal health care services: perspectives from a demand and supply side intervention in Eastern Uganda 
Introduction
High maternal and infant mortality continue to be major challenges to the attainment of the Millennium Development Goals for many low and middle-income countries. There is now evidence that voucher initiatives can increase access to maternal health services. However, a dearth of knowledge exists on the cost implications of voucher schemes. This paper estimates the incremental costs of a demand and supply side intervention aimed at increasing access to maternal health care services.
Methods
This costing study was part of a quasi-experimental voucher study conducted in two districts in Eastern Uganda to explore the impact of demand and supply - side incentives on increasing access to maternal health services. The provider’s perspective was used and the ingredients approach to costing was employed. Costs were based on market prices as recorded in program records. Total, unit, and incremental costs were calculated.
Results
The estimated total financial cost of the intervention for the one year of implementation was US$525,472 (US$1 = 2200UgShs). The major cost drivers included costs for transport vouchers (35.3%), health system strengthening (29.2%) and vouchers for maternal health services (18.2%). The average cost of transport per woman to and from the health facility was US$4.6. The total incremental costs incurred on deliveries (excluding caesarean section) was US$317,157 and US$107,890 for post natal care (PNC). The incremental costs per additional delivery and PNC attendance were US$23.9 and US$7.6 respectively.
Conclusion
Subsidizing maternal health care costs through demand and supply – side initiatives may not require significant amounts of resources contrary to what would be expected. With Uganda’s Gross Domestic Product (GDP) per capita of US$55` (2012), the incremental cost per additional delivery (US$23.9) represents about 5% of GDP per capita to save a mother and probably her new born. For many low income countries, this may not be affordable, yet reliance on donor funding is often not sustainable. Alternative ways of raising additional resources for health must be explored. These include; encouraging private investments in critical sectors such as rural transport, health service provision; mobilizing households to save financial resources for preparedness, and financial targeting for the most vulnerable.
doi:10.1186/1478-7547-12-14
PMCID: PMC4074383  PMID: 24976793
Vouchers; Maternal health; Costs; Sustainability; Demand-side; Supply-side
17.  Private and public health care in rural areas of Uganda 
Background
In many low and middle income countries, the private sector is increasingly becoming an important source of health care, filling gaps where no or little public health care is available. However, knowledge on the private sector providers is limited The objective of this study was to determine the type and number of different types of health care providers, and the quality, cost and utilization of care delivered by those providers in rural Uganda.
Methods
The study was carried out in three rural districts. Methods included (1) mapping of health care providers; (2) a household survey to determine morbidity and health care utilization; (3) a health facility survey to assess quality of care; (4) focus group discussions to get qualitative information on providers and provider choice; and (5) key informant interviews to further explore service characteristics.
Results
95.7% of all 445 facilities surveyed were private while 4.3% were public. Traditional practitioners and general merchandise shops that sold medicines comprised 77.1% of all providers. They had limited infrastructure and skills but were often located in the villages and therefore easily accessible. Among the formal providers there were 4 times as many private for profit providers than public, 76 versus 18. However, most of the private units were one-person drug shops.
In the household survey, 2580 persons were interviewed. 1097 (42%) had experienced illness during the preceding month. Care was sought in 54.1% of the cases. 35.6% were given self-treatment and in 10.3% no action was taken. Of the episodes for which people sought care at a health care facility, 37.0% visited a public health care provider, 39.7% a for profit provider, 11.8% a private not for profit provider, and 10.6% a traditional practitioner. Private for profit facilities were the most popular for ambulatory health care, while public facilities were preferred for more serious conditions and for hospitalization. Traditional practitioners were many but saw relatively few patients. They were mostly used for social problems and limited medical specific conditions.
Conclusions
Private providers play a major role in health care delivery in rural Uganda; reaching a wide client base. Traditional practitioners are many but have as much a social as a medical function in the community. The significance of the private health care sector points to the need to establish a policy that addresses quality and affordability issues and creates a strong regulatory environment for private practice in sub-Saharan Africa.
doi:10.1186/1472-698X-10-29
PMCID: PMC3003635  PMID: 21106099
18.  Cost of mental and behavioural disorders in Kenya 
Background
The health and economic impact of mental and behavioural disorders (MBD) is wide-ranging, long-lasting and large. Unfortunately, unlike in developed countries where studies on the economic burden of MBD exist, there is a dearth of such studies in the African Region of the World Health Organization. Yet, a great need for such information exists for use in sensitizing policy-makers in governments and civil society about the magnitude and complexity of the economic burden of MBD. The purpose of this study was to answer the following question: From the societal perspective (specifically the families and the Ministry of Health), what is the total cost of MBD patients admitted to various public hospitals in Kenya?
Methods
Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health care system and the family in directly addressing the problem of MBD; and (b) the indirect costs, i.e. loss of productivity caused by MBD, which is borne by the individual, the family or the employer. The study was based on Kenyan public hospitals, either dedicated to care of MBD patients or with a MBD ward.
Results
The study revealed that: (i) in the financial year 1998/99, the Kenyan economy lost approximately US$13,350,840 due to institutionalized MBD patients; (ii) the total economic cost of MBD per admission was US$2,351; (iii) the unit cost of operating and organizing psychiatric services per admission was US$1,848; (iv) the out-of-pocket expenses borne by patients and their families per admission was US$51; and (v) the productivity loss per admission was US$453.
Conclusions
There is an urgent need for research in all African countries to determine: national-level epidemiological burden of MBD, measured in terms of the prevalence, incidence, mortality, and, probably, the disability-adjusted life-years lost; and the economic burden of MBD, broken down by different productive and social sectors and occupations of patients and relatives.
doi:10.1186/1475-2832-2-7
PMCID: PMC169183  PMID: 12892565
19.  Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor? 
Background
Uganda implemented health sector reforms to make services more accessible to the population. An assessment of the likely impact of these reforms is important for informing policy. This paper describes the changes in utilization of health services that occurred among the poor and those in rural areas between 2002/3 and 2005/6 and associated factors.
Methods
Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset based index derived from Principal Components Analysis (PCA). The probability of choice of health care provider was assessed using multinomial logistic regression and multi-level statistical models.
Results
The odds of not seeking care in 2005/6 were 1.79 times higher than in 2002/3 (OR = 1.79; 95% CI 1.65 - 1.94). The rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access (OR = 0.57; 95% CI 0.48 - 0.67). The risk of not seeking care due to high costs did not change significantly. Private for profit providers (PFP) were the major providers of services in 2002/3 and 2005/6. Using PFP as base category, respondents were more likely to have used private not for profit (PNFP) in 2005/6 than in 2002/3 (OR = 2.15; 95% CI 1.58 - 2.92), and also more likely to use public facilities in 2005/6 than 2002/3 (OR = 1.31; 95% CI 1.15 - 1.48). The most poor, females, rural residents, and those from elderly headed households were more likely to use public facilities relative to PFP.
Conclusion
Although overall utilization of public and PNFP services by rural and poor populations had increased, PFP remained the major source of care. The odds of not seeking care due to distance decreased in rural areas but cost continued to be an important barrier to seeking health services for residents from poor, rural, and elderly headed households. Policy makers should consider targeting subsidies to the poor and rural populations. Public private partnerships should be broadened to increase access to health services among the vulnerable.
doi:10.1186/1475-9276-8-39
PMCID: PMC2781807  PMID: 19909514
20.  Public-sector Maternal Health Programmes and Services for Rural Bangladesh 
Achieving Millennium Development Goal 5 in Bangladesh calls for an appreciation of the evolution of maternal healthcare within the national health system to date plus a projection of future needs. This paper assesses the development of maternal health services and policies by reviewing policy and strategy documents since the independence in 1971, with primary focus on rural areas where three-fourths of the total population of Bangladesh reside. Projections of need for facilities and human resources are based on the recommended standards of the World Health Organization (WHO) in 1996 and 2005. Although maternal healthcare services are delivered from for-profit and not-for-profit (NGO) subsectors, this paper is focused on maternal healthcare delivery by public subsector. Maternal healthcare services in the public sector of Bangladesh have been guided by global policies (e.g. Health for All by the Year 2000), national policies (e.g. population and health policy), and plans (e.g. five- or three-yearly). The Ministry of Health and Family Welfare (MoHFW), through its two wings—Health Services and Family Planning—sets policies, develops implementation plans, and provides rural public-health services. Since 1971, the health infrastructure has developed though not in a uniform pattern and despite policy shifts over time. Under the Family Planning wing of the MoHFW, the number of Maternal and Child Welfare Centres has not increased but new services, such as caesarean-section surgery, have been integrated. The Health Services wing of the MoHFW has ensured that all district-level public-health facilities, e.g. district hospitals and medical colleges, can provide comprehensive essential obstetric care (EOC) and have targeted to upgrade 132 of 407 rural Upazila Health Complexes to also provide such services. In 2001, they initiated a programme to train the Government's community workers (Family Welfare Assistants and Female Health Assistants) to provide skilled birthing care in the home. However, these plans have been too meagre, and their implementation is too weak to fulfill expectations in terms of the MDG 5 indicator—increased use of skilled birth attendants, especially for poor rural women. The use of skilled birth attendants, institutional deliveries, and use of caesarean section remain low and are increasing only slowly. All these indicators are substantially lower for those in the lower three socioeconomic quintiles. A wide variation exists in the availability of comprehensive EOC facilities in the public sector among the six divisions of the country. Rajshahi division has more facilities than the WHO 1996 standard (1 comprehensive EOC for 500,000 people) whereas Chittagong and Sylhet divisions have only 64% of their need for comprehensive EOC facilities. The WHO 2005 recommendation (1 comprehensive EOC for 3,500 births) suggests that there is a need for nearly five times the existing national number of comprehensive EOC facilities. Based on the WHO standard 2005, it is estimated that 9% of existing doctors and 40% of nurses/midwives were needed just for maternal healthcare in both comprehensive EOC and basic EOC facilities in 2007. While the inability to train and retain skilled professionals in rural areas is the major problem in implementation, the bifurcation of the MoHFW (Health Services and Family Planning wings) has led to duplication in management and staff for service-delivery, inefficiencies as a result of these duplications, and difficulties of coordination at all levels. The Government of Bangladesh needs to functionally integrate the Health Services and Family Planning wings, move towards a facility-based approach to delivery, ensure access to key maternal health services for women in the lower socioeconomic quintiles, consider infrastructure development based on the estimation of facilities using the WHO 1996 recommendation, and undertake a human resource-development plan based on the WHO 2005 recommendation.
PMCID: PMC2761780  PMID: 19489411
Maternal health; Maternal health services; Rural health services; Bangladesh
21.  Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa 
PLoS Medicine  2011;8(11):e1001132.
Emmanuel Njeuhmeli and colleagues estimate the impact and cost of scaling up adult medical male circumcision in 13 priority countries in eastern and southern Africa, finding that reaching 80% coverage and maintaining it until 2025 would avert 3.36 million new HIV infections.
Background
There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data.
Methods and Findings
We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion.
Conclusions
This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs.
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Every year, about 2.5 million people (mainly in sub-Saharan Africa) become infected with HIV, the virus that causes AIDS. There is no cure for HIV/AIDS. Consequently, prevention of HIV transmission is very important. Because the most common HIV transmission route is through unprotected sex with an infected partner, individuals can reduce their risk of HIV infection by abstaining from sex, by having only one or a few partners, and by using male or female condoms. There is also strong evidence that voluntary medical male circumcision (VMMC)—the removal of the foreskin, the loose fold of skin that covers the head of the penis—reduces the heterosexual acquisition of HIV in men by about 60%. In 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that VMMC should be offered to men as part of comprehensive HIV risk reduction programs in settings with generalized HIV epidemics and low levels of male circumcision. They also prioritized 13 countries in eastern and southern Africa for VMMC program scale-up.
Why Was This Study Done?
The impact of VMMC scale-up in terms of HIV infections and AIDS deaths averted (epidemiologic impact) is expected to be large, and the intervention should also reduce the costs associated with the treatment, care, and support of infected individuals. However, VMMC scale-up will require substantial funding and considerable effort by countries—many of which have weak health systems and limited resources—to train personnel, equip facilities, and provide the necessary commodities. To support planning for VMMC scale-up, the United States Agency for International Development Health Policy Initiative has collaborated with UNAIDS to develop the Decision Makers' Program Planning Tool (DMPPT), a mathematical model that allows analysts and decision makers to estimate the epidemiologic impact and cost of alternative VMMC scale-up programs. In this study, the researchers use DMPPT to estimate the impact and cost of scaling up adult VMMC in the 13 priority countries in eastern and southern Africa.
What Did the Researchers Do and Find?
The researchers derived VMMC unit costs for each priority country based on a cost assessment undertaken in Zimbabwe, one of the first countries to scale up VMMC services using WHO's “Models for Optimizing Volume and Efficiencies” (MOVE) guidelines. They fed these costs and recent epidemiologic data (including HIV infection rates and the effectiveness of VMMC in preventing HIV transmission) and demographic data (including the adult population size and pre-scale-up male circumcision prevalence) collected in each country into the DMPPT, together with information on the lifetime costs of HIV treatment. Results from running the DMPPT model suggest that scaling up adult VMMC to reach 80% coverage in the 13 priority countries by 2015 would require 20.33 million circumcisions to be completed between 2011 and 2015. To maintain this coverage, a further 8.42 million circumcisions would be required between 2016 and 2025. Such a scale-up would avert 3.36 million new HIV infections through 2025 and would cost US$2,000,000,000 between 2011 and 2025. However, it would result in net savings (because of averted treatment and care costs) of US$16,510,000,000.
What Do These Findings Mean?
These findings suggest that rapid VMMC scale-up in eastern and southern Africa is warranted, given its likely impact on the region's HIV epidemics and the resultant cost savings. However, the accuracy of these findings depends on the assumptions built into the DMPPT and on the data fed into it. For example, there could be risk behavior changes after circumcision. That is, risky sexual behaviors may increase in men who have been circumcised. However, the researchers show that, except in Rwanda, post-circumcision risk behavior change is unlikely to completely reverse the benefits of VMMC. These modeling results also assume that men seeking out VMMC services are typical of the general male population, but if they are actually at unusually low risk of HIV infection, then the benefits of VMMC reported here are likely to be overestimated. Finally, these findings assume 80% VMMC coverage. This may be optimistic, although results from Kenya indicate that this target is achievable. Thus, countries and their international partners must allocate sufficient resources to VMMC scale-up to achieve high coverage rates if they are to take full advantage of the benefits predicted here for VMMC scale-up.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001132.
This study is part of a PLoS Collection of articles on http://www.ploscollections.org/VMMC2011 and is further discussed in a PLoS Medicine Review Article by Hankins et al. (http://dx.doi.org/10.1371/journal.pmed.1001127)
Information is available from WHO, UNAIDS, and PEPFAR on all aspects of HIV/AIDS; the 2011WHO/UNAIDS progress report on VMMC scale-up in the 13 priority countries is available
NAM/aidsmap provides basic information about HIV/AIDS, summaries of recent research findings on HIV care and treatment, and information on male circumcision for the prevention of HIV transmission
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on all aspects of HIV prevention, and on HIV/AIDS in Africa (in English and Spanish)
The Clearinghouse on Male Circumcision, a resource provided by WHO, UNAIDS, and other international bodies, provides information and tools for VMMC policy development and program implementation, including information on the DMPPT and the MOVE guidance
Personal stories about living with HIV/AIDS are available through Avert, through NAM/aidsmap, and through the charity website Healthtalkonline
doi:10.1371/journal.pmed.1001132
PMCID: PMC3226464  PMID: 22140367
22.  Healthy Firms: Constraints to Growth among Private Health Sector Facilities in Ghana and Kenya 
PLoS ONE  2012;7(2):e27885.
Background
Health outcomes in developing countries continue to lag the developed world, and many countries are not on target to meet the Millennium Development Goals. The private health sector provides much of the care in many developing countries (e.g., approximately 50 percent in Sub-Saharan Africa), but private providers are often poorly integrated into the health system. Efforts to improve health systems performance will need to include the private sector and increase its contributions to national health goals. However, the literature on constraints private health care providers face is limited.
Methodology/Principal Findings
We analyze data from a survey of private health facilities in Kenya and Ghana to evaluate growth constraints facing private providers. A significant portion of facilities (Ghana: 62 percent; Kenya: 40 percent) report limited access to finance as the most significant barrier they face; only a small minority of facilities report using formal credit institutions to finance day to day operations (Ghana: 6 percent; Kenya: 11 percent). Other important barriers include corruption, crime, limited demand for goods and services, and poor public infrastructure. Most facilities have paper-based rather than electronic systems for patient records (Ghana: 30 percent; Kenya: 22 percent), accounting (Ghana: 45 percent; Kenya: 27 percent), and inventory control (Ghana: 41 percent; Kenya: 24 percent). A majority of clinics in both countries report undertaking activities to improve provider skills and to monitor the level and quality of care they provide. However, only a minority of pharmacies report undertaking such activities.
Conclusions/Significance
The results suggest that improved access to finance and improving business processes especially among pharmacies would support improved contributions by private health facilities. These strategies might be complementary if providers are more able to take advantage of increased access to finance when they have the business processes in place for operating a successful business and health facility.
doi:10.1371/journal.pone.0027885
PMCID: PMC3286467  PMID: 22383944
23.  Private Hospital Sector Development: An Exploratory Study on Providers Perspective in Addis Ababa, Ethiopia 
Ethiopian Journal of Health Sciences  2011;21(Suppl 1):59-64.
Background
Over the past decade there is a trend of fast development in the private hospital sector in Ethiopia. This important component of the health care system has received policy attention and federal government is a promoter for private health care. Yet lack of basic data on the factors affecting the growth of private health care provision in the country and no studies are available on this issue in Ethiopia. The aim of this study is to get some preliminary insights on the factors affecting the growth and development of private hospital sector in Addis Ababa, Ethiopia with perspective of provider.
Methods
A hospital based qualitative study was conducted in 25 for-profit hospitals in Addis Ababa using key informant in-depth interviews and secondary data was collected from Federal Ministry of Health and Addis Ababa City Health Administration and private hospital providers.
Results
The findings of the study suggest that private hospital sector is expanding significantly in recent years in Ethiopia. The active role of government is a catalyst for the growth of private facilities in the country. Factors outside the health are growing disposable income, improvements in literacy, road networks, population growth and long standing diseases, all contribute to the trend. But private providers are facing many problems, like availability of trained manpower, escalation of costs, availability and quality of drugs and financing mechanisms.
Conclusion
Private hospital sector is expanding in Ethiopia. But private providers are vulnerable to imperfections in the existing market structure. Government and professional bodies need to make a concerted effort to address these issues and design appropriate strategies to promote and regulate this sector effectively.
PMCID: PMC3275879  PMID: 22435009
Private hospital sector; Development; Providers
24.  Introducing a model of cardiovascular prevention in Nairobi's slums by integrating a public health and private-sector approach: the SCALE-UP study 
Global Health Action  2013;6:10.3402/gha.v6i0.22510.
Introduction
Cardiovascular disease (CVD) is a leading cause of death in sub-Saharan Africa (SSA), with annual deaths expected to increase to 2 million by 2030. Currently, most national health systems in SSA are not adequately prepared for this epidemic. This is especially so in slum settlements where access to formal healthcare and resources is limited.
Objective
To develop and introduce a model of cardiovascular prevention in the slums of Nairobi by integrating public health and private sector approaches.
Study design
Two non-profit organizations that conduct public health research, Amsterdam Institute for Global Health and Development (AIGHD) and African Population and Health Research Center (APHRC), collaborated with private-sector Boston Consulting Group (BCG) to develop a service delivery package for CVD prevention in slum settings. A theoretic model was designed based on the integration of public and private sector approaches with the focus on costs and feasibility.
Results
The final model includes components that aim to improve community awareness, a home-based screening service, patient and provider incentives to seek and deliver treatment specifically for hypertension, and adherence support. The expected outcomes projected by this model could prove potentially cost effective and affordable (1 USD/person/year). The model is currently being implemented in a Nairobi slum and is closely followed by key stakeholders in Kenya including the Ministry of Health, the World Health Organization (WHO), and leading non-governmental organizations (NGOs).
Conclusion
Through the collaboration of public health and private sectors, a theoretically cost-effective model was developed for the prevention of CVD and is currently being implemented in the slums of Nairobi. If results are in line with the theoretical projections and first impressions on the ground, scale-up of the service delivery package could be planned in other poor urban areas in Kenya by relevant policymakers and NGOs.
doi:10.3402/gha.v6i0.22510
PMCID: PMC3805842  PMID: 24149078
hypertension; cardiovascular diseases; prevention; health system; slums; Africa
25.  Treatment Outcomes and Cost-Effectiveness of Shifting Management of Stable ART Patients to Nurses in South Africa: An Observational Cohort 
PLoS Medicine  2011;8(7):e1001055.
Lawrence Long and colleagues report that “down-referring” stable HIV patients from a doctor-managed, hospital-based ART clinic to a nurse-managed primary health facility provides good health outcomes and cost-effective treatment for patients.
Background
To address human resource and infrastructure shortages, resource-constrained countries are being encouraged to shift HIV care to lesser trained care providers and lower level health care facilities. This study evaluated the cost-effectiveness of down-referring stable antiretroviral therapy (ART) patients from a doctor-managed, hospital-based ART clinic to a nurse-managed primary health care facility in Johannesburg, South Africa.
Methods and Findings
Criteria for down-referral were stable ART (≥11 mo), undetectable viral load within the previous 10 mo, CD4>200 cells/mm3, <5% weight loss over the last three visits, and no opportunistic infections. All patients down-referred from the treatment-initiation site to the down-referral site between 1 February 2008 and 1 January 2009 were compared to a matched sample of patients eligible for down-referral but not down-referred. Outcomes were assigned based on vital and health status 12 mo after down-referral eligibility and the average cost per outcome estimated from patient medical record data.
The down-referral site (n = 712) experienced less death and loss to follow up than the treatment-initiation site (n = 2,136) (1.7% versus 6.2%, relative risk = 0.27, 95% CI 0.15–0.49). The average cost per patient-year for those in care and responding at 12 mo was US$492 for down-referred patients and US$551 for patients remaining at the treatment-initiation site (p<0.0001), a savings of 11%. Down-referral was the cost-effective strategy for eligible patients.
Conclusions
Twelve-month outcomes of stable ART patients who are down-referred to a primary health clinic are as good as, or better than, the outcomes of similar patients who are maintained at a hospital-based ART clinic. The cost of treatment with down-referral is lower across all outcomes and would save 11% for patients who remain in care and respond to treatment. These results suggest that this strategy would increase treatment capacity and conserve resources without compromising patient outcomes.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
AIDS has killed more than 25 million people since 1981, and about 33 million people are now infected with HIV, the virus that causes AIDS. Because HIV destroys immune system cells, which leaves infected individuals susceptible to other infections, early in the AIDS epidemic, most HIV-infected people died within ten years of infection. Then, in 1996, antiretroviral therapy (ART), which can keep HIV in check for many years, became available. For people living in developed countries, HIV infection became a chronic condition, but people in developing countries were not so lucky—ART was prohibitively expensive and so a diagnosis of HIV infection remained a death sentence in many regions of the world. In 2003, this situation was declared a global health emergency, and governments, international agencies, and funding bodies began to implement plans to increase ART coverage in developing countries. As a result, nowadays, more than a third of people in low- and middle-income countries who need ART are receiving it.
Why Was This Study Done?
Unfortunately, shortages of human resources in developing countries are impeding progress toward universal ART coverage. In sub-Saharan Africa, for example, where two-thirds of all HIV-positive people live, there are too few doctors to supervise all the ART that is required. Various organizations are therefore encouraging a shift of clinical care responsibilities for people receiving ART from doctors to less highly trained, less expensive, and more numerous members of the clinical workforce. Thus, in South Africa, plans are underway to reduce the role of hospital doctors in ART and to increase the role of primary health clinic nurses. One specific strategy involves “down-referring” patients whose HIV infection is under control (“stable ART patients”) from a doctor-managed, hospital-based ART clinic to a nurse-managed primary health care facility. In this observational study, the researchers investigate the effect of this strategy on treatment outcomes and costs by retrospectively analyzing data collected from a cohort (group) of adult patients initially treated by doctors at the Themba Lethu Clinic in Johannesburg and then down-referred to a nearby primary health clinic where nurses supervised their treatment.
What Did the Researchers Do and Find?
Patients attending the hospital-based ART clinic were invited to transfer to the down-referral site if they had been on ART for at least 11 months and met criteria that indicated that ART was controlling their HIV infection. Each of the 712 stable ART patients who agreed to be down-referred to the primary health clinic was matched to three patients eligible for down-referral but not down-referred (2,136 patients), and clinical outcomes and costs in the patient groups were compared 12 months after down-referral eligibility. At this time point, 1.7% of the down-referred patients had died or had been lost to follow up compared to 6.2% of the patients who continued to receive hospital-based ART. The average cost per patient-year for those in care and responding at 12 months was US$492 for down-referred patients but US$551 for patients remaining at the hospital. Finally, the down-referral site spent US$509 to produce a patient who was in care and responding one year after down-referral on average, whereas the hospital spent US$602 for each responding patient. Thus, the down-referral strategy (nurse-managed care) was more cost-effective than continued hospital treatment (doctor-managed care).
What Do These Findings Mean?
These findings indicate that, at least for this pair of study sites, the 12-month outcomes of stable ART patients who were down-referred to a primary health clinic were as good as or better than the outcomes of similar patients who remained at a hospital-based ART clinic. Moreover, the down-referral strategy saved 11% of costs for patients who remained in care and responded to treatment and appeared to be cost-effective, although additional studies are needed to confirm this last finding. Because this is an observational study (that is, patients eligible for down-referral were not randomly assigned to hospital or primary care facility treatment), it is possible that some unknown factor was responsible for the difference in outcomes between the two patient groups. Nevertheless, these results suggest that the down-referral strategy tested in this study could increase ART capacity and conserve resources without compromising patient outcomes in South Africa and possibly in other resource-limited settings.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/journal.pmed.pmed.1001055.
This study is further discussed in a PLoS Medicine Perspective by Ford and Mills
The US National Institute of Allergy and Infectious Diseases provides information on HIV infection and AIDS
HIV InSite has comprehensive information on HIV/AIDS
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and AIDS in Africa and on universal access to AIDS treatment (in English and Spanish)
The World Health Organization provides information about universal access to AIDS treatment, including its 2010 progress report (in English, French and Spanish)
Right to Care, a non-profit organization that aims to deliver and support quality clinical services in Southern Africa for the prevention, treatment, and management of HIV, provides information on down-referral
doi:10.1371/journal.pmed.1001055
PMCID: PMC3139666  PMID: 21811402

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