Browsing by Author "Obse, Amarech"

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    A critical assessment of the Rwandan health financing system: implications for health service utilisation
    (2025) Hakuzimana, Alex; Ataguba, John Ele-Ojo; Obse, Amarech; Cunnama, Lucy
    Like many other countries, Rwanda has embraced major health financing reforms to achieve universal health coverage goals and improve access to quality health services without undue financial hardship for its citizens. The public health sector provides most health services in the country, and fragmentation is a major challenge to its health financing system. Literature suggests that fragmentation of health financing may negatively impact the health system's equity, efficiency, and sustainability. Considering the currently available literature, this thesis critically assessed Rwanda's health financing system in relation to the equitable use of health care services, one of the goals of universal health coverage. Various methodological approaches to address different objectives are explored. A case study qualitative approach combining document review and in-depth interviews of key informants indicates that the Rwandan health financing system is fragmented. Using the data from the 2005/2006 and 2010/2011 Integrated Household Living Conditions Surveys, this research shows that despite this fragmentation and contrary to findings from other studies, there was no inequality in public health services use during the two separate periods. These results provide further opportunities for more health sector reforms to improve access to affordable public health services in Rwanda. They also support recommendations to conduct similar analyses to compare these findings with the most recent data to capture the current reality on the equitable use of health care services in public health facilities.
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    Open Access
    Sensitivity of measuring the progress in financial risk protection to varied survey instruments: A case study of Ghana
    (2021) Sumboh, Jemima Ambamaah Catherine; Ataguba, John; Obse, Amarech
    Valid and reliable data on household health expenditure and other household consumption expenditure are important for monitoring the progress towards Universal Health Coverage (UHC). However, the difficulty in obtaining reliable estimates of private expenditure on health often undermine the credibility of health accounts, limit the tracking of financial resources, and make international comparisons extremely difficult. This study assessed the sensitivity of estimates of out-of-pocket health payments and catastrophic health expenditure to the choice of survey instruments. The study used a household budget survey dataset collected in Ghana, in 2017/2018 by the Navrongo Health Research Center. The health expenditure questions were disaggregated into three different levels: Versions I, II and III containing 11, 44 and 56 health expenditure items, respectively. The number of non-health items and recall periods, however, were held constant across versions. Catastrophic health expenditure was measured as out-of-pocket health expenditure that exceeded a certain fraction of household non-food expenditure, depending on the socioeconomic group. Concentration indices were also used to determine the concentration of catastrophic health expenditure. The mean and median household out-of-pocket health expenditure per annum ranged from US$74.11 to USD$106.49, and US$13.69 to US$20.33, respectively depending on the type of survey instrument used. Also, between 7.98% and 12.68% of households incurred catastrophic out-of-pocket health payments, depending on the survey instrument used. The findings show that estimates of out-of-pocket health spending and financial catastrophe are sensitive to the level of disaggregation of out-of-pocket health spending questions in survey instruments. The concentration indices for catastrophic headcount and overshoot were all negative across all catastrophic threshold levels and data versions implying that catastrophic health payments are concentrated among poor households. Further research is needed, preferably validation studies, to enhance the reliability and comparability of estimates of OOP health expenditure and catastrophic health expenditure.
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    Social determinants of comorbid depression among patients living with diabetes and/or HIV at primary healthcare settings in Western Cape Province of South Africa
    (2025) Tintinger, Susanet; Obse, Amarech; Cunnama, Lucy
    The co-occurrence of physical and mental health conditions poses a significant public health challenge globally especially in low- and middle-income countries (LMICs). In South Africa, diabetes, HIV, and depression frequently co-occur in an intricate manner, and the illness experience is largely shaped by the differences between individuals, communities, and provinces. Previous research highlights the influence of socioeconomic factors on the relationship between diabetes, HIV, and depression, although the focus has mainly been on the variability in health outcomes explained by individual-level factors. There is a need for evidence on the mental health outcome variations attributable to distinct contextual levels amongst patients living with HIV and/or diabetes. This dissertation assesses the socioeconomic determinants of depressive symptoms among patients living with HIV and/or diabetes accessing healthcare at the primary health care (PHC) level in the Western Cape province. Furthermore, it examines the variation in depressive symptoms attributable to individual, household, and community levels among this sub-population. Baseline data collected from participants in a cluster randomised controlled trial, named Project MIND conducted in the Western Cape, was used in this analysis. This study applied a three-level multi-level logistic regression analysis. Random intercepts were added at the household and community levels using grouping variables for household socioeconomic status and PHC catchment areas to account for the heterogeneity across the data hierarchy levels. Four random intercept multi-level models were fitted sequentially. The estimated intraclass correlation coefficients (ICCs) were used to determine the proportion of the outcome variance attributable to the grouping- and individual-level variables for each model. Overall, the findings indicate that the variance in depressive symptoms among patients with HIV and/or diabetes can be explained by differences at the household- and community-levels when controlling for individual-level factors. Higher odds of moderate to severe depressive symptoms were significantly associated with being female, secondary level education, and food insecurity. Lower odds of moderate to severe depressive symptoms were associated with harmful/hazardous alcohol use, increased social support, and increased self-efficacy. This study highlights the importance of policies that simultaneously consider individual, household- and community-levels to address co-occurring mental and physical health conditions in the Western Cape. The findings support interventions at the PHC level and in the community to bolster social support systems and self-efficacy, promote mental health from early educational years, prioritise gender-sensitive health programs, and address household food insecurity among patients living with HIV and/or diabetes with depressive symptoms.
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    The effects of Performance-Based Financing on the uptake of health services in low-and-middle-income countries: A systematic review
    (2023) Ezeogu, Obioma; Obse, Amarech
    Background Many low- and middle-income countries (LMICs) have adopted Performance-Based Financing (PBF) since the late nineties to improve health system effectiveness and efficiency. Two previous systematic literature reviews assessed the effect of PBF on the uptake of specific health services such as HIV/AIDs and modern family planning. Another two assessed its effect on different aspects of the health system including health outcomes. This systematic review specifically assessed the effects of PBF implemented in LMICs on uptake of health services. Method Relevant scientific databases include PubMed, Academic Search Premier, Africa Wide Information, APA Psych Info, Business Source Premier, CINAHL, COCHRANE, EconLit, SCOPUS, Humanities International Complete, African Index Medicus, IndMed, Business Source Premier and Web of Science for: - randomised control trials, contemporaneous comparative studies, time-series studies, and impact evaluation papers published between 2000 and 2019 that evaluated PBF and its effect on the uptake or use of health services. A narrative synthesis was used due to wide variations in the methodologies of the included papers. Result Fifteen papers were eligible for analysis, and they are from Asia (3) and sub-Saharan Africa (8), the rests are literature reviews (4). PBF had mixed effects on uptake of targeted health care services in general but specifically showed great promise in the uptake of institutional delivery. It also improved the quality of care and had a mixed effect on equity. Limitations The research produced contemporary evidence on the effect of PBF on the utilization of health care services in LMICs. Furthermore, besides public health institutions especially primary health care centres, it also assessed the effect of PBF on faith-based clinics, and among informal health care providers thereby giving a holistic view of the effect of PBF, reflecting the contexts of LMICs. A major limitation is that the sample size is small to make a generalized conclusion on the effect of PBF on the uptake of health care services in LMICs. Another limitation is that only peer r eviewed paper s wer e analysed and they have diverse methodological approaches and varied contexts, hence unsuitable to conduct a meta-analysis. Again, the research was conducted using papers published in English alone, which limits the resources available to analyse the outcome effect. Conclusion PBF had a mixed effect on the uptake of targeted health care services in LMICs, more research is needed for robust evidence; to substantiate PBF's effect on improving, for example institutional delivery to reduce maternal mortality in LMICs.