OpenUCT :: Browsing by Author "McIntyre, Diane"

Browsing by Author "McIntyre, Diane"

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Open Access
Addressing health inequalities in South Africa : policy insights and the role of improved efficiency
(2002) Asbu, Eyob Zere; McIntyre, Diane
This study attempts to assess the equity and technical efﬁciency aspects of the South African health system. It empirically assesses the status qua and trends in equity as it relates to child morbidity and mortality and self-reported illness and utilization of different service providers in adulthood. Furthermore, an assessment of the technical efﬁciency and productivity of a sample of public sector hospitals is conducted. This is meant to explore the size of potential efficiency gains that is tantamount to the injection of additional resources, which are highly needed for addressing inequities in a scenario where mobilization of additional resources from the public purse is seriously constrained as a result of poor economic performance, stringent ﬁscal policies and competing priorities, among other things. Secondary data are used in the analyses. These include data from the Living Standards and Development Survey (LSDS) of 1993, conducted jointly by the World Bank and the South African Labour and Development Research Unit at the University of Cape Town, and data from the October Household Survey (OHS) series (OHS 1995 and OHS 1998) that are conducted annually by Statistics South Africa. For the analysis of hospital efﬁciency, data are obtained from annual statistical publications of provincial health departments. The equity analysis is done using concentration indices (and curves). In the adult population, standardized concentration indices are computed to rule out a possible confounding effect of the demographic variables, age and gender. Furthermore, utilization of services is standardized for need as measured by self-reported acute or chronic illness. Additionally, to identify some factors, which may be associated with inequities in child health, probit models are estimated. Data envelopment analysis (DEA) and DEA-based Maimquist productivity index are used to examine the state of hospital technical efﬁciency and productivity respectively. With the limited data available a tobit regression is also run to identify factors influencing the technical efﬁciency of hospitals. Overall, the ﬁndings of this study indicate that the huge income-related inequalities in health and health care that existed prior to the change of the political system in 1994 have been reduced signiﬁcantly in the years after the installation of the new government. Analyses of the LSDS 1993 indicate signiﬁcant pro-rich inequities in all the dimensions of equity in health and health care utilization examined in this study. Under-ﬁve mortality and child malnutrition manifest pro-rich inequalities of high magnitude. In the adult population, as is seen in many other studies, pro-poor inequities are seen in self-reported acute illness. This paradoxical pro-poor ﬁnding is, however, changed to pro-rich inequalities in the OHS 1995 and 1998 data. Inequalities in under-ﬁve mortality in the OHS 1998 data that do not show when income is used as a measure of socio-economic status (SES) are prominently seen when SES is proxied by race and residential location. This implies that the apparent bridging of inequities seen when income is used as a measure of SES may not enable us to definitively assert the absence of socio-economic inequities in health. Utilization statistics from all data sets indicate pro-poor horizontal inequities in the use of primary and other public health facilities, implying an appropriate targeting of public sector health care resources. The data clearly show that considerable health and health system inequities remain in South Africa. In order to rapidly address these inequities, additional resources are required to improve health and other health-promoting services in currently under-served areas and for speciﬁc disadvantaged groups. However, given the macro-economic context, the allocation of additional resources to the health sector is unlikely. The hospital sector, which absorbs the lion's share of the public health resources, seems to be plagued by high degrees of technical inefficiency. With the prevailing high levels of technical inefficiency and the adverse economic realities of the country, it would be difﬁcult to mobilize additional resources needed for addressing existing inequities. Hence it is of paramount importance to address the existing technical inefficiencies in the hospital sector. Finally the study recommends that to address the inequities that besiege the country's health system, policies that transcend the health sector are needed and that there is an urgent need to rectify existing inefﬁciencies.
Open Access
An analysis of the impact of generic medicine reference pricing in a sector of the South African private healthcare insurance industry
(2015) Noble-Luckhoff, Jennifer Anne; McIntyre, Diane
Background: Pharmaceuticals are responsible for a substantial percentage of the total cost of health care and continue to exceed economic growth and inflation. Generic medicines play an important role in limiting this expenditure, and consequently there is an international drive to implement pro - generic policies particularly in high income countries. One such policy is generic medicine reference pricing (GRP). Generic reference pricing sets a fixed maximum reimbursement amount for clusters of bio - equivalent drugs without placing any restrictions on the manufacturers' price. Numerous studies have been conducted in high income countries to analyse the impact of generic reference pricing; however, the impact of this reference pricing in low - to - middle income countries (LMIC s) is not well established. Objective: This dissertation aims to address this lack of information in LMICs by providing empirical aggregated claims data on the impact of generic reference pricing on price, expenditure, utilisation and out - of - pocket (OOP) p ayments in a sector of South Africa's private health insurance industry. Methods: This time series intervention study of retrospective claim - level secondary data analyses the impact of one of several generic reference pricing models applied by various private medical insurance companies in South Africa. Criteria applied for the selection of referenced categories and sample claims data intend to maximize the data set as well as the analysis period, while minimizing confounders such as medical insurance member variation and specific managed care policies. The impact of the reference price on variables of drug price, drug expenditure, market share and out - of - pock et payment is measured by analysing changes in the originator, 'authorised generic' ('clone') and generic drugs within each cluster. (An 'authorised generic' (AG) is an exact copy of the originator, approved as a brand - name drug under a patent protection but marketed as a generic.) Results: Two referenced priced categories (Desloratadine and Clopidogrel) and a population of approximately 100,000 were identified as being eligible for inclusion. An authorised generic was launched for Clopidogrel but not for Desloratadine. The implementation of generic reference pricing appears to have had no or minimal impact on the price of the originator and authorised generic - at the end of the study period the price of the originator drugs of the two categories was 268% and 86% higher than the reference and the authorised generic of Clopidogrel was 69 % higher than the reference price. Most often the reference price appeared to be based on the price of a generic drug; however once the reference price was set other generics tended to align at or below the reference price. The implementation of generic reference pricing was associated with an overall increase in dispensed volumes and a decrease in expenditure for both categories; both categories' originator market share declined dramatically by volume (to 23% and 4%) and value (to 35% and 9 %). For Clopidogrel the authorised generic took the majority of market share (63% by volume and 68% by value); the generics only gained one third of the market, despite lower product prices and minimal co - payments. Desloratadine generics captured 80% of the market by the end of the study. For both categories there was no notable change in the total drug expenditure paid out - of - pocket across the study period. The percentage of drugs dispensed that had a co - payment decreased dramatically for Desloratadine, but were only seen to decrease marginally for Clopidogrel. Limitations: Due to the small sample and limited reference categories analysed, the findings from this study are not representative of the South African private healthcare sector and cannot be extrapolated to South Africa. In addition, any savings identified should take the expense of non - referenced alternatives into account.
Open Access
A cost-effectiveness analysis of the tuberculosis control procedures applied in the Cape Divisional Council area
(1987) McIntyre, Diane; Archer, Sean; Simkins, Charles
This study evaluates the costs and effectiveness of preventive and curative procedures currently available for Tuberculosis (TB) control purposes. The procedures examined are as follows : i) BCG vaccinations; ii) Secondary chemoprophylaxis; iii) Health education; iv) Mass screening campaigns; v) Investigation of contacts of infectious TB cases and symptomatic persons, i.e. suspects; and vi) Treatment regimens for notified TB patients. The analysis is largely based on data from the records of 300 randomly selected TB patients, treated at clinics in the Cape Divisional Council area in 1983. The major finding of this study is that resources available for TB control should be reallocated in the direction of secondary chemoprophylaxis, BCG vaccination administration in the Black and Coloured populations, investigation of contacts and suspects, and ambulatory treatment of notified TB patients. Conversely, vaccinating the White population, mass screening campaigns and hospitalisation of TB patients should be given relatively less emphasis in the overall TB control programme. In addition, the proportion of patients confirmed as TB cases by means of bacteriological examinations should be increased to reduce misdiagnosis.
Open Access
Economic evaluation of task-shifting approaches to the dispensing of anti-retroviral therapy
(BioMed Central Ltd, 2012) Foster, Nicola; McIntyre, Diane
BACKGROUND:A scarcity of human resources for health has been identified as one of the primary constraints to the scale-up of the provision of Anti-Retroviral Treatment (ART). In South Africa there is a particularly severe lack of pharmacists. The study aims to compare two task-shifting approaches to the dispensing of ART: Indirectly Supervised Pharmacist's Assistants (ISPA) and Nurse-based pharmaceutical care models against the standard of care which involves a pharmacist dispensing ART. METHODS: A cross-sectional mixed methods study design was used. Patient exit interviews, time and motion studies, expert interviews and staff costs were used to conduct a costing from the societal perspective. Six facilities were sampled in the Western Cape province of South Africa, and 230 patient interviews conducted. RESULTS: The ISPA model was found to be the least costly task-shifting pharmaceutical model. However, patients preferred receiving medication from the nurse. This related to a fear of stigma and being identified by virtue of receiving ART at the pharmacy. CONCLUSIONS: While these models are not mutually exclusive, and a variety of pharmaceutical care models will be necessary for scale up, it is useful to consider the impact of implementing these models on the provider, patient access to treatment and difficulties in implementation.
Open Access
Exploring inequalities in access to and use of maternal health services in South Africa
(BioMed Central Ltd, 2012) Silal, Sheetal; Penn-Kekana, Loveday; Harris, Bronwyn; Birch, Stephen; McIntyre, Diane
BACKGROUND: South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country's Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, "patient-oriented" barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. METHODS: A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers. RESULTS: Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care. CONCLUSIONS: To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these "patient-oriented" barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.
Open Access
Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy
(2018) Okungu, Vincent; Chuma, Jane; Mulupi, Stephen; McIntyre, Diane
Universal health coverage (UHC) is important in terms of improving access to quality health care while protecting households from the risk of catastrophic health spending and impoverishment. However, progress to UHC has been hampered by the measures to increase mandatory prepaid funds especially in low- and middle-income countries where there are large populations in the informal sector. Important considerations in expanding coverage to the informal sector should include an exploration of the type of prepayment system that is acceptable to the informal sector and the features of such a design that would encourage prepayment for health care among this population group. The objective of the study was to document the views of informal sector workers regarding different prepayment mechanisms, and critically analyze key design features of a future health system and the policy implications of financing UHC in Kenya.
Open Access
Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy
(BioMed Central, 2018-01-09) Okungu, Vincent; Chuma, Jane; Mulupi, Stephen; McIntyre, Diane
Background: Universal health coverage (UHC) is important in terms of improving access to quality health care while protecting households from the risk of catastrophic health spending and impoverishment. However, progress to UHC has been hampered by the measures to increase mandatory prepaid funds especially in low- and middleincome countries where there are large populations in the informal sector. Important considerations in expanding coverage to the informal sector should include an exploration of the type of prepayment system that is acceptable to the informal sector and the features of such a design that would encourage prepayment for health care among this population group. The objective of the study was to document the views of informal sector workers regarding different prepayment mechanisms, and critically analyze key design features of a future health system and the policy implications of financing UHC in Kenya. Methods: This was part of larger study which involved a mixed-methods approach. The following tools were used to collect data from informal sector workers: focus group discussions [N = 16 (rural = 7; urban = 9)], individual in-depth interviews [N = 26 (rural = 14; urban = 12)] and a questionnaire survey [N = 455(rural = 129; urban = 326)]. Thematic approach was used to analyze qualitative data while Stata v.11 involving mainly descriptive analysis was used in quantitative data. The tools mentioned were used to collect data to meet various objectives of a larger study and what is presented here constitutes a small section of the data generated by these tools. Results: The findings show that informal sector workers in rural and urban areas prefer different prepayment systems for financing UHC. Preference for a non-contributory system of financing UHC was particularly strong in the urban study site (58%). Over 70% in the rural area preferred a contributory mechanism in financing UHC. The main concern for informal sector workers regardless of the overall design of the financing approach to UHC included a poor governance culture especially one that does not punish corruption. Other reasons especially with regard to the contributory financing approach included high premium costs and inability to enforce contributions from informal sector. Conclusion: On average 47% of all study participants, the largest single majority, are in favor of a noncontributory financing mechanism. Strong evidence from existing literature indicates difficulties in implementing social contributions as the primary financing mechanism for UHC in contexts with large informal sector populations. Noncontributory financing should be strongly recommended to policymakers to be the primary financing mechanism and supplemented by social contributions.
Open Access
Inequities in under-five child malnutrition in South Africa
(BioMed Central Ltd, 2003) Zere, Eyob; McIntyre, Diane
OBJECTIVES:To assess and quantify the magnitude of inequalities in under-five child malnutrition, particularly those ascribable to socio-economic status and to consider the policy implications of these findings. METHODS: Data on 3765 under-five children were derived from the Living Standards and Development Survey. Household income, proxied by per capita household expenditure, was used as the main indicator of socio-economic status. Socio-economic inequality in malnutrition (stunting, underweight and wasting) was measured using the illness concentration index. The concentration index was calculated for the whole sample, as well as for different population groups, areas of residence (rural, urban and metropolitan) and for each province. RESULTS: Stunting was found to be the most prevalent form of malnutrition in South Africa. Consistent with expectation, the rate of stunting is observed to be the highest in the Eastern Cape and the Northern Province - provinces with the highest concentration of poverty. There are considerable pro-rich inequalities in the distribution of stunting and underweight. However, wasting does not manifest gradients related to socio-economic position. Among White children, no inequities are observed in all three forms of malnutrition. The highest pro-rich inequalities in stunting and underweight are found among Coloured children and metropolitan areas. There is a tendency for high pro-rich concentration indices in those provinces with relatively lower rates of stunting and underweight (Gauteng and the Western Cape). CONCLUSION: There are significant differences in under-five child malnutrition (stunting and underweight) that favour the richest of society. These are unnecessary, avoidable and unjust. It is demonstrated that addressing such socio-economic gradients in ill-health, which perpetuate inequalities in the future adult population requires a sound evidence base. Reliance on global averages alone can be misleading. Thus there is a need for evaluating policies not only in terms of improvements in averages, but also improvements in distribution. Furthermore, addressing problems of stunting and underweight, which are found to be responsive to improvements in household income status, requires initiatives that transcend the medical arena.
Open Access
Promoting equitable access to health care for households
(2014-09-19) McIntyre, Diane; Gilson, Lucy
To develop an understanding of the dimensions of access to health care; Create greater awareness of health care access constraints from the household perspective; Promote critical evaluation of policy options to address access constraints in relation to equity goals; Promote and strengthen effective development and implementation of equitable health sector policies. The idea for developing this set of training materials arose from the ‘Affordability Ladder Program’ (ALPS). The ALPS initiative focused on the experience of households of illness and of seeking health care. As the name would suggest, a key focus of ALPS was that of affordability and other aspects of access to health care for households. The ALPS team recognised that almost all of the training materials presently available focus on illness and health services from the health system’s perspective, with little or no attention devoted to the perspective of households. In addition, few of the available materials focus explicitly on the issue of equity, which should be seen as a priority in the context of growing awareness of substantial inequities in existing health systems; the majority of training materials are presently directed towards efforts to promote efficiency of health services. This was seen as an important gap, in that health care managers and policy makers will be better placed to design and implement health care policies and detailed plans that meet population needs if they are aware of the experience of households and if equity is the ‘lens’ through which alternative policies are considered. Finally, despite access to health care being a key policy objective by many countries, there is a lack of clarity about how access is defined and what constitutes access. It is, thus, also important to explore the different aspects of access in greater detail so that equitable access can become a reality. On this basis, it was decided to develop a set of training materials that present participants with an equity ‘lens’ through which to view the challenges of promoting health system access, focusing attention on households’ experience of illness and health service access. TARGET GROUPS: The training materials can be used for a diverse set of target groups, but are primarily aimed at current and future health sector managers. It is also envisaged that the case studies can be used on an ad-hoc basis in post-graduate programs such as Masters in Public Health programs. CASE STUDY MATERIALS: Six case studies have been prepared for this course: *Experiences of households in Sri Lanka; *Availability of health services and resource allocation; *Affordability of drugs in the context of the World Trade Organisation (WTO); *Tax and insurance funding for health systems; *Health service acceptability issues; *Access board game
Open Access
Should countries implementing an artemisinin-based combination malaria treatment policy also introduce rapid diagnostic tests?
(BioMed Central Ltd, 2008) Zikusooka, Charlotte; McIntyre, Diane; Barnes, Karen
BACKGROUND: Within the context of increasing antimalarial costs and or decreasing malaria transmission, the importance of limiting antimalarial treatment to only those confirmed as having malaria parasites becomes paramount. This motivates for this assessment of the cost-effectiveness of routine use of rapid diagnostic tests (RDTs) as an integral part of deploying artemisinin-based combination therapies (ACTs). METHODS: The costs and cost-effectiveness of using RDTs to limit the use of ACTs to those who actually have Plasmodium falciparum parasitaemia in two districts in southern Mozambique were assessed. To evaluate the potential impact of introducing definitive diagnosis using RDTs (costing $0.95), five scenarios were considered, assuming that the use of definitive diagnosis would find that between 25% and 75% of the clinically diagnosed malaria patients are confirmed to be parasitaemic. The base analysis compared two ACTs, artesunate plus sulfadoxine/pyrimethamine (AS+SP) costing $1.77 per adult treatment and artemether-lumefantrine (AL) costing $2.40 per adult treatment, as well as the option of restricting RDT use to only those older than six years. Sensitivity analyses considered lower cost ACTs and RDTs and different population age distributions. RESULTS: Compared to treating patients on the basis of clinical diagnosis, the use of RDTs in all clinically diagnosed malaria cases results in cost savings only when 29% and 52% or less of all suspected malaria cases test positive for malaria and are treated with AS+SP and AL, respectively. These cut-off points increase to 41.5% (for AS+SP) and to 74% (for AL) when the use of RDTs is restricted to only those older than six years of age. When 25% of clinically diagnosed patients are RDT positive and treated using AL, there are cost savings per malaria positive patient treated of up to $2.12. When more than 29% of clinically diagnosed cases are malaria test positive, the incremental cost per malaria positive patient treated is less than US$ 1. When relatively less expensive ACTs are introduced (e.g. current WHO preferential price for AL of $1.44 per adult treatment), the RDT price to the healthcare provider should be $0.65 or lower for RDTs to be cost saving in populations with between 30 and 52% of clinically diagnosed malaria cases being malaria test positive. CONCLUSION: While the use of RDTs in all suspected cases has been shown to be cost-saving when parasite prevalence among clinically diagnosed malaria cases is low to moderate, findings show that targeting RDTs at the group older than six years and treating children less than six years on the basis of clinical diagnosis is even more cost-saving. In semi-immune populations, young children carry the highest risk of severe malaria and many healthcare providers would find it harder to deny antimalarials to those who test negative in this age group.
Open Access
The social determinants of HIV among men who have sex with men in Cape Town, South Africa
(2014) Scheibe, Andrew; McIntyre, Diane; Bekker, Linda-Gail; Ekström, Anna Mia
Includes abstract. Includes bibliographical references.
Metadata only
Transforming Health Systems: Case studies of critical health system analyses to support reform
(2014-08-21) McIntyre, Diane; Gilson, Lucy
A set of case studies to enhance critical analysis for health system reform. Over the years, the Health Economics Unit (University of Cape Town) and Centre for Health Policy (University of the Witwatersrand) have developed a range of training materials to strengthen critical analysis skills that can support health system reform. One of the case studies considers how national health accounts data can contribute to critically assessing existing health systems to identify key challenges that could potentially be addressed through reforms. The two key areas of health system reform focused on in these training materials are health care financing and decentralisation. These are complemented by case studies on resource allocation between and within health districts. While technical skills are important for health system reform, so are skills to understand and manage key policy actors or stakeholders. The set of materials, therefore, concludes with case studies to develop stakeholder analysis skills.
Open Access
Who pays for health care in Ghana?
(BioMed Central Ltd, 2011) Akazili, James; Gyapong, John; McIntyre, Diane
BACKGROUND:Financial protection against the cost of unforeseen ill health has become a global concern as expressed in the 2005 World Health Assembly resolution (WHA58.33), which urges its member states to "plan the transition to universal coverage of their citizens". An important element of financial risk protection is to distribute health care financing fairly in relation to ability to pay. The distribution of health care financing burden across socio-economic groups has been estimated for European countries, the USA and Asia. Until recently there was no such analysis in Africa and this paper seeks to contribute to filling this gap. It presents the first comprehensive analysis of the distribution of health care financing in relation to ability to pay in Ghana. METHODS: Secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used. This was triangulated with data from the Ministry of Finance and other relevant sources, and further complemented with primary household data collected in six districts. We implored standard methodologies (including Kakwani index and test for dominance) for assessing progressivity in health care financing in this paper. RESULTS: Ghana's health care financing system is generally progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes, which account for close to 50% of health care funding. The national health insurance (NHI) levy (part of VAT) is mildly progressive and formal sector NHI payroll deductions are also progressive. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are regressive form of health payment to households. CONCLUSION: For Ghana to attain adequate financial risk protection and ultimately achieve universal coverage, it needs to extend pre-payment cover to all in the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the National Health Insurance. Furthermore, the pre-payment funding pool for health care needs to grow so budgetary allocation to the health sector can be enhanced.

Browsing by Author "McIntyre, Diane"

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