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1.  Direct facility funding as a response to user fee reduction: implementation and perceived impact among Kenyan health centres and dispensaries 
Health policy and planning  2010;25(5):406-418.
There is increasing pressure for reduction of user fees, but this can have adverse effects by decreasing facility-level funds. To address this, direct facility funding (DFF) was piloted in Coast Province, Kenya, with health facility committees (HFCs) responsible for managing the funds. We evaluated the implementation and perceived impact 2.5 years after DFF introduction.
Quantitative data collection at 30 public health centres and dispensaries included a structured interview with the in-charge, record reviews and exit interviews. In addition, in-depth interviews were conducted with the in-charge and HFC members at 12 facilities, and with district staff and other stakeholders.
DFF procedures were well established: HFCs met regularly and accounting procedures were broadly followed. DFF made an important contribution to facility cash income, accounting for 47% in health centres and 62% in dispensaries. The main items of expenditure were wages for support staff (32%), travel (21%), and construction and maintenance (18%). DFF was perceived to have a highly positive impact through funding support staff such as cleaners and patient attendants, outreach activities, renovations, patient referrals and increasing HFC activity. This was perceived to have improved health worker motivation, utilization and quality of care.
A number of problems were identified. HFC training was reportedly inadequate, and no DFF documentation was available at facility level, leading to confusion. Charging user fees above those specified in the national policy remained common, and understanding of DFF among the broader community was very limited. Finally, relationships between HFCs and health workers were sometimes characterized by mistrust and resentment.
Relatively small increases in funding may significantly affect facility performance when the funds are managed at the periphery. Kenya plans to scale up DFF nationwide. Our findings indicate this is warranted, but should include improved training and documentation, greater emphasis on community engagement, and insistence on user fee adherence.
doi:10.1093/heapol/czq009
PMCID: PMC2929466  PMID: 20211967
Kenya; health care financing; health facility committees; community engagement; user fees
2.  Direct facility funding as a response to user fee reduction: implementation and perceived impact among Kenyan health centres and dispensaries 
Health Policy and Planning  2010;25(5):406-418.
There is increasing pressure for reduction of user fees, but this can have adverse effects by decreasing facility-level funds. To address this, direct facility funding (DFF) was piloted in Coast Province, Kenya, with health facility committees (HFCs) responsible for managing the funds. We evaluated the implementation and perceived impact 2.5 years after DFF introduction.
Quantitative data collection at 30 public health centres and dispensaries included a structured interview with the in-charge, record reviews and exit interviews. In addition, in-depth interviews were conducted with the in-charge and HFC members at 12 facilities, and with district staff and other stakeholders.
DFF procedures were well established: HFCs met regularly and accounting procedures were broadly followed. DFF made an important contribution to facility cash income, accounting for 47% in health centres and 62% in dispensaries. The main items of expenditure were wages for support staff (32%), travel (21%), and construction and maintenance (18%). DFF was perceived to have a highly positive impact through funding support staff such as cleaners and patient attendants, outreach activities, renovations, patient referrals and increasing HFC activity. This was perceived to have improved health worker motivation, utilization and quality of care.
A number of problems were identified. HFC training was reportedly inadequate, and no DFF documentation was available at facility level, leading to confusion. Charging user fees above those specified in the national policy remained common, and understanding of DFF among the broader community was very limited. Finally, relationships between HFCs and health workers were sometimes characterized by mistrust and resentment.
Relatively small increases in funding may significantly affect facility performance when the funds are managed at the periphery. Kenya plans to scale up DFF nationwide. Our findings indicate this is warranted, but should include improved training and documentation, greater emphasis on community engagement, and insistence on user fee adherence.
doi:10.1093/heapol/czq009
PMCID: PMC2929466  PMID: 20211967
Kenya; health care financing; health facility committees; community engagement; user fees
3.  Price Elasticity Estimates for Tobacco Products in India 
Health policy and planning  2008;23(3):200-209.
The tax base of tobacco in India is heavily dependent on about 14% of tobacco users, who smoke cigarettes. Non-cigarette tobacco products accounting for 85% of the tobacco consumption contributes only 15% of the total tobacco taxes. Though taxation is an important tool to regulate consumption of tobacco, there have been no estimates of price elasticities for different tobacco products in India to date, which can guide tax policy on tobacco. This paper, for the first time in India, examines the price elasticity of demand for bidis, cigarettes and leaf tobacco at the national level using a representative cross-section of households. This study found that own-price elasticity estimates of different tobacco products in India ranged between −0.4 to −0.9, with bidis (an indigenous hand-rolled smoked tobacco preparation in India) and leaf tobacco having elasticities close to unity. Cigarettes were the least price elastic of all. With some assumptions, it is shown that the tax on bidis can be increased to Rs. 100 per 1000 sticks compared with the current Rs. 14 and the tax on an average cigarette can be increased to Rs. 3.5 per stick without any fear of losing revenue. The paper argues that the current system of taxing cigarettes in India based on the presence of filters and the length of cigarettes has no justification on health grounds, and should be abolished, if reducing tobacco consumption and the consequent disease burden is one of the objectives of tobacco taxation policy. It also argues that attempts to regulate tobacco use without effecting significant tax increases on bidis may not produce desired results.
doi:10.1093/heapol/czn007
PMCID: PMC2800993  PMID: 18424474
Tobacco; bidis; cigarettes; consumption; elasticity; India
4.  Regulating Tanzania’s drug shops -- why do they break the rules, and does it matter? 
Health policy and planning  2007;22(6):393-403.
Regulatory infringements are extremely common in low income countries, especially with respect to retail pharmaceutical sales. There have been few practical suggestions on public policy responses other than stricter regulatory enforcement, which governments are often unable, or unwilling, to do. This paper explores the challenges of regulating retail drug sellers, and potential solutions, through a case study of malaria treatment in rural Tanzania where small drug shops are a common source of medicine.
Infringement of health-related regulation was extremely common. Most stores lacked valid permits, and illegal stocking of prescription-only medicines and unpackaged tablets was the norm. Most stocked unregistered drugs, and no serving staff met the qualification requirements. Infringements are likely to have reflected infrequent regulatory inspections, a failure of regulatory authorities to implement sanctions, successful concealment of regulatory violations, and the tacit permission of local regulatory staff.
Eliminating regulatory infringements is unlikely to be feasible, and could be undesirable if access to essential medicines is reduced. Alternatives include bringing official drug regulation closer into line with locally legitimate practices; greater use of positive incentives for providers; and consumer involvement. Such a change in approach has the potential to provide a firmer platform for public-private collaboration to improve shop-based treatment.
doi:10.1093/heapol/czm033
PMCID: PMC2657823  PMID: 17921151
6.  Cost and cost-effectiveness of nationwide school-based helminth control in Uganda 
Health policy and planning  2007;23(1):24-35.
Estimates of cost and cost-effectiveness are typically based on a limited number of small-scale studies with no investigation of the existence of economies to scale or intra-country variation in cost and cost-effectiveness. This information gap hinders the efficient allocation of health care resources and the ability to generalize estimates to other settings. The current study investigates the intra-country variation in the cost and cost-effectiveness of nationwide school-based treatment of helminth (worm) infection in Uganda. Programme cost data were collected through semi-structured interviews with districts officials and from accounting records in six of the 23 intervention districts. Both financial and economic costs were assessed. Costs were estimated on the basis of cost in US$ per schoolchild treated and an incremental cost effectiveness ratio (cost in US$ per case of anaemia averted) was used to evaluate programme cost-effectiveness. Sensitivity analysis was performed to assess the effect of discount rate and drug price. The overall economic cost per child treated in the six districts was US$ 0.54 and the cost-effectiveness was US$ 3.19 per case of anaemia averted. Analysis indicated that estimates of both cost and cost-effectiveness differ markedly with the total number of children which received treatment, indicating economies of scale. There was also substantial variation between districts in the cost per individual treated (US$ 0.41-0.91) and cost per anaemia case averted (US$ 1.70-9.51). Independent variables were shown to be statistically associated with both sets of estimates. This study highlights the potential bias in transferring data across settings without understanding the nature of observed variations.
doi:10.1093/heapol/czm041
PMCID: PMC2637386  PMID: 18024966
cost analysis; cost-effectiveness; economic evaluation; variation; scaling up; helminth control; Uganda
7.  Health sector reform in the Occupied Palestinian Territories (OPT): targeting the forest or the trees? 
Health policy and planning  2003;18(1):59-67.
Since the signing of the Oslo Peace Accords and the establishment of the Palestinian Authority in 1994, reform activities have targeted various spheres, including the health sector. Several international aid and UN organizations have been involved, as well as local and international non-governmental organizations, with considerable financial and technical investments. Although important achievements have been made, it is not evident that the quality of care has improved or that the most pressing health needs have been addressed, even before the second Palestinian Uprising that began in September 2000. The crisis of the Israeli re-invasion of Palestinian-controlled towns and villages since April 2002 and the attendant collapse of state structures and services have raised the problems to critical levels. This paper attempts to analyze some of the obstacles that have faced reform efforts. In our assessment, those include: ongoing conflict, frail Palestinian quasi-state structures and institutions, multiple and at times inappropriate donor policies and practices in the health sector, and a policy vacuum characterized by the absence of internal Palestinian debate on the type and direction of reform the country needs to take. In the face of all these considerations, it is important that reform efforts be flexible and consider realistically the political and economic contexts of the health system, rather than focus on mere narrow technical, managerial and financial solutions imported from the outside.
PMCID: PMC1457109  PMID: 12582108
health sector reform; conflict; Occupied Palestinian Territories
8.  Caesarean section rates in the Arab region: a cross-national study 
Health policy and planning  2004;19(2):101-110.
This study had a dual purpose of estimating population- and hospital-based caesarean section rates in 18 Arab countries and examining the association between these rates and important indicators of socioeconomic development. Data on caesarean section were based on the most recent population-based surveys undertaken in each country. Descriptive statistics and bivariate correlation coefficients were used for the analysis. Specifically, Spearman’s rank correlation coefficients were used to analyze the associations between caesarean section rates and important population parameters. Results revealed that four Arab countries had population-based caesarean rates below 5%, while only three countries had rates above 15%. The remaining 11 countries had caesarean rates ranging between 5–15%. Higher hospital-based rates were reported for all countries. Differences in caesarean section rates between private and public hospitals were also noted. Highly significant associations were observed between population caesarean rates and female literacy, percentage urban, infant mortality rate, and the proportion of physicians per 100 000 people. The ‘caesarean section epidemic’ observed in countries of Latin America is not yet evident in the 18 Arab countries examined. Rather, emphasis should be on improving access to appropriate obstetrical interventions in case of complications in a number of countries where rates were well below 5%.
PMCID: PMC1457106  PMID: 14982888
caesarean section; socioeconomic development; health system; Arab countries

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