Browsing by Subject "Health Economics"

Now showing 1 - 20 of 158
  • Thumbnail Image
    Item
    Open Access
    A comparative cost analysis of the pathway to diagnosing lymphoma in a tertiary hospital, Western Cape, South Africa
    (2022) Fareed-Brey, Waarisa; Cunnama, Lucy; Verburgh, Estelle; Antel, Katherine
    Cancer is one of the leading causes of death before the age of 70 in 91 countries (out of 172) with a noted increasing incidence of cancer and mortality (Bray et al., 2018). In tuberculosis (TB) endemic areas, a fine needle aspirate (FNA) is often used as the diagnostic tool of choice when trying to understand the underlying cause of lymphadenopathy (LAP), which can lead to delayed diagnosis of lymphoma (Antel et al., 2019). A significant gap exists in the lack of costing of the diagnostic pathway to diagnosing lymphoma. The study aimed to cost the diagnostic pathways, namely FNA, core-needle biopsy (CNB), and surgical excision biopsy (SEB) using secondary data collected in 2018 (February until October) at Groote Schuur Hospital (GSH), within the tertiary level hospital outpatient clinics to informed the patient pathways. The overall purpose of the study was to inform policy-making decisions and process guidelines. A cost analysis study was conducted using a combination of ingredients-based costing and top-down costing from a provider's perspective. Annual costs were calculated and inflated to 2021 South African Rands using the consumer price index (CPI) and converted to United States American Dollars. More CNBs are currently being performed than SEBs at GSH, and when pathways were followed, CNB initiated pathways (US $567) were less costly compared to FNA initiated pathways (US$ 877). The cost of the CNB procedure varied with the use of a single-use biopsy gun and the multi-use Magnum BARD gun. CNB provides an alternate choice to SEB and based on the study conducted, CNB pathways are less costly. The main cost driver for all three procedures was personnel and this could be decreased by task shifting and training of medical officers and interns.
  • Thumbnail Image
    Item
    Open Access
    A Retrospective, Observational Study of Medico-legal Cases against Obstetricians and Gynaecologists in South Africa's Private Sector
    (2020) Taylor, Bettina; Cleary, Susan
    South Africa is experiencing a medico-legal crisis that is threatening the delivery of essential health care services, especially relating to maternal and fetal health. In the private sector, professional indemnity premiums for obstetricians to provide insurance cover in the event of medico-legal challenges have increased more than 10-fold in a 10-year period. In the State, exponential increases in contingent liabilities for claims due to alleged negligence are usurping health care budgets allocated towards the delivery of health care, with about half of these claims relating to obstetrics and gynaecology and three quarter of latter to cerebral palsy for reasons of alleged hypoxic brain injury of the newborn. Despite the ominous implications of these developments for the supply side of health care, there is a scarcity of information in terms of contributing factors. Whilst many assume that the main driving force of burgeoning professional indemnity premiums for obstetricians and gynaecologists in the private sector have also been as a result of claims for cerebral palsy, there are no empirical data to explain developments over recent years and guide risk management interventions in this regard. To understand claim trends and identify potential predictors of patient dissatisfaction that result in engagement of the regulatory and legal system in the private sector, obstetric and gynaecological medico-legal data recorded by Constantia Insurance Limited, a local professional indemnity provider, were analysed. Other than confirming a steep increase in medico-legal notifications for obstetric- and gynaecology-related complaints from about 2003 to 2012, a high proportion of number of claims and paid settlements for gynaecology relative to obstetric-related cases was noted. This is contrary to international and public sector experiences, where number of demands relating to obstetrics consistently exceed those associated with gynaecological care. This finding, together with the fact that the majority of pay-outs on behalf of doctors related to surgical complications, especially unintended intraoperative injuries to internal organs and vessels, calls for further research into the clinical outcomes of private gynaecological practice, as well as potential review of aspects of surgical training standards and accreditation in gynaecology and consideration of surgical mentorship programmes. The latter is particularly relevant in the context of surgical registrars having expressed concerns about their readiness to practice independently following specialist graduation. Whereas claims for severe neurological injury of the newborn constituted less than 15% of all claims settled on behalf of obstetricians and gynaecologists entered into the study, they accounted for about half of all known paid settlements relating to pregnancy-related care. Whilst not dominating in terms of claim frequency overall, they nevertheless are an important focus area for risk management interventions, given the high quantum of demand typically associated with these cases. In this regard, more research into the etiology of errors is required, including the contribution of nursing and other system failures that could not be quantified adequately as part of this research project. Another important finding was the disproportionate contribution of medico-legal risk by a small cohort of practitioners, which suggests a need for doctor-focused support and interventions, including effective peer review and regulatory oversight by the Health Professions Council. To reverse the high financial burden of professional indemnity fees and fear of litigation amongst private sector obstetricians and gynaecologists, multidimensional risk management interventions, which include enhancements at the point of care, are required. If medicolegal trends and their negative consequences are to be reversed, medico-legal hotspots should become an important source of information and consideration in the development of solutions aimed at preventing human error and strengthening the healthcare system in terms of improved patient safety and satisfaction.
  • Thumbnail Image
    Item
    Open Access
    A Sensitivity Analysis Framework for Health Economic Evaluation in Middle Income Countries: Appropriately Incorporating a Comprehensive Approach
    (2021) Soboil, Joshua; Cunnama, Lucy; Wilkinson, Tommy
    When constructing a health economic decision model, it is critical to select a sensitivity analysis approach appropriate for the decision context. This point is particularly salient to Middle-Income Countries (MICs), where there is relatively heightened resource scarcity and increased opportunity-cost. MICs face acute shortages of accessible as well as highquality evidence, resulting in a frequent imputing of data from external jurisdictions. Conversely, there are also shortages in skills and research capacity, creating a strong complementary need to consider the contextual feasibility of applying more resource demanding sensitivity analysis methodologies. Given the above, it is therefore critical to establish whether and when the technical benefits of complex and resource demanding methods result in real-world value. We apply a comparative case study using a comprehensive approach to decision-modelling, implemented in the R and JAGS languages. Specifically, the case study replicates a deterministic model originally used to inform the cost-effectiveness of adding a bivalent Human Papilloma Virus (HPV) vaccine to South Africa's public health care cervical cancer screening programme. Crucially, the case study provides critical insight into the pros and cons of implementing more complex sensitivity analysis techniques within MIC climates. Our findings indicate that the benefits of more advanced sensitivity analysis methods are nuanced; are therefore contextually beneficial according to a case-by-case basis; and, moreover, choosing a sensitivity analysis method should be guided by a conceptual ‘fruitfulness' (i.e. a bang-for-buck), more than a mere desire to reduce model complexity. To aid analysts in this process, from our comparative case study we provide a framework with three core concept areas namely Decision-Maker Preferences (Decision Power, Investment, Risk Aversion), Analytical Considerations (Available resources, Indirect Evidence) and Policy Context (Knowledge of Topic, Technical Expertise). The framework intends to encourage more judicious selection of sensitivity analysis methods; help reduce the methodological variation apparent in MIC settings; and simultaneously provide decision-makers with greater methodological transparency in the selection of sensitivity analysis methods.
  • Thumbnail Image
    Item
    Open Access
    Absorptive capacity to finance HIV/AIDS treatment in South Africa: Where are the bottlenecks?
    (2010) Irurzun Lopez, Maria Teresa; Sinanovic, Edina; Booysen, Frikkie
    This research investigates absorptive capacity in South Africa's public health sector in relation to scaling up financing for HIV/AIDS treatment. The thesis constructs a conceptual framework, which follows the flow of public funding for HIV/AIDS treatment. The study combines a quantitative budget analysis, which looks at expenditure and spending patterns, with qualitative in-depth interviews with key stakeholders exploring causes and consequences, which are the main pillar of the primary research. The study applies the conceptual framework nationally, as well as in the Free State and Western Cape provinces. The contributions of the thesis are two-fold: At the conceptual level, the study defines and constructs an analytical framework of absorptive capacity and related bottlenecks in the context of funding for HIV/AIDS treatment in the public health sector. It identifies five major areas where bottlenecks may arise: financial, human, infrastructural, institutional (within the health system) and structural (outside the health system). At the empirical level, the study assesses and compares absorptive capacity and major bottlenecks encountered nationally and in the Free State and Western Cape provinces in respect of the public sector funding for the HIV/AIDS treatment programme. The results confirm that absorptive capacity is not merely about spending funding. Spending should not compromise other programs or elements of the public health system, and it should be efficient, equitable and sustainable. The findings show that South Africa's absorptive capacity was constrained by several obstacles, such as poor practices and a shortage of human resources, insufficient financial capacity and demanding requirements of conditional funding, inadequate infrastructure, and inadequate national leadership. To overcome these obstacles, the mere injection of even more funding would be an insufficient response. Consequently, the study indicates which other reforms are required, including: further integrating antiretroviral treatment services within the public health structures; further decentralising antiretroviral treatment towards primary health care; task shifting; iii balancing the conditional grant and equitable share; and enhancing coordination between the National and Provincial Departments of Health and with Treasury.
  • Thumbnail Image
    Item
    Open Access
    Acceptability of access to child health care, in the rural area around Zithulele Hospital in the Eastern Cape
    (2011) Shillington, Lucy; Honda, Ayako
    This study is from the perspective of rural South Africa using the case of Zithulele Hospital as an area of interest. The research is qualitative in nature and will make use of both focus group discussions and key informant inter-views, in order to assess the access to child health care provided at Zithulele Hospital. The focus will be on the acceptability of access to child health care and more specifically, the acceptability of treatment for diarrhoeal disease.
  • Thumbnail Image
    Item
    Open Access
    Acceptability to general practitioners of national health insurance and capitation as a reimbursement mechanism
    (1999) Blecher, Mark Stephen; Bachmann, Max; McIntyre, Di
    Objective: The objectives of the study were to determine General Practitioners' attitudes to National Health Insurance (NHI) and to capitation as a mechanism of reimbursement. The study also aimed to explore determinants of these attitudes. Design: The methodology utilised a cross-sectional survey using telephone interviews and four focus group discussions. Setting: The study area was the Cape Peninsula area in the Western Cape Province of South Africa. Participants: 174 general practitioners (GPs) were randomly sampled from a total population of 874 GPs in the Cape Peninsula area. Main outcome measures: The main outcome measures were GPs' acceptance of NHI and of capitation as a method of reimbursement. Main results: Sixty three percent of GPs (63,3%) approved of NHI. More than 81 % approved of NHI if GPs were to maintain their independent status, for example their own premises and working hours. Eighty two percent (82,3%) said NHI would be a more equitable system of health care than the system that existed at that time, 88% approved of the fact that NHI would make care by GPs more accessible and 73% said they had the capacity to treat more patients. However, 61,3% of GPs disapproved of capitation as a form of reimbursement. The most common conditions cited by GPs for support of NHI were retention of professional autonomy, fee for service reimbursement and adequate levels of reimbursement. Conclusions: Most GPs in the Cape Peninsula were amenable to some form of NHI. However, approval of NHI is to some extent conditional to details of the NHI system, such as payment mechanisms, workload, income and effects on professional autonomy. The implications of GPs' preferences concerning the reimbursement mechanism for the feasibility of implementing a NHI in South Africa requires serious consideration by policy makers. While this research demonstrates broad ideological and conceptual support for some form of NHI or SHI, further research is required to provide more detailed quantitative information on the trade-offs that GPs would be prepared to make for them to support the introduction of a new socially based insurance system. A national survey of medical practitioners is recommended.
  • Thumbnail Image
    Item
    Open Access
    Access barriers to antiretroviral therapy (ART) in Zimbabwe: a case study of Chivhu Hospital
    (2012) Siduna, Willie; Cleary, Susan
    Access to healthcare is one of the basic social goods which ensures that individuals lead healthy and long lives. There is an increased need towards ensuring access to health care for all, which has led to the question of how access is defined. Access in this study is defined as the degree of fit between the health care system and patients. It involves an interaction between the system and patients in a way which removes access barriers to care. A comprehensive framework was used to measure access in this study. The framework allows for a systematic approach to the concept of access and measures access in three dimensions namely affordability, availability and acceptability. Using this framework, the study looked into the factors affecting access to antiretroviral therapy (ART) by patients at Chivhu Hospital in Zimbabwe. Chivhu was chosen because it has a mixed population of urban and rural patients which represents the typical Zimbabwean population. A cross sectional study design was adopted for this study.
  • Thumbnail Image
    Item
    Open Access
    Achieving universal health care coverage: Current debates in Ghana on covering those outside the formal sector
    (BioMed Central Ltd, 2012) Abiiro, Gilbert; McIntyre, Di
    BACKGROUND: Globally, extending financial protection and equitable access to health services to those outside the formal sector employment is a major challenge for achieving universal coverage. While some favour contributory schemes, others have embraced tax-funded health service cover for those outside the formal sector. This paper critically examines the issue of how to cover those outside the formal sector through the lens of stakeholder views on the proposed one-time premium payment (OTPP) policy in Ghana.DISCUSSION:Ghana in 2004 implemented a National Health Insurance Scheme, based on a contributory model where service benefits are restricted to those who contribute (with some groups exempted from contributing), as the policy direction for moving towards universal coverage. In 2008, the OTPP system was proposed as an alternative way of ensuring coverage for those outside formal sector employment. There are divergent stakeholder views with regard to the meaning of the one-time premium and how it will be financed and sustained. Our stakeholder interviews indicate that the underlying issue being debated is whether the current contributory NHIS model for those outside the formal employment sector should be maintained or whether services for this group should be tax funded. However, the advantages and disadvantages of these alternatives are not being explored in an explicit or systematic way and are obscured by the considerable confusion about the likely design of the OTPP policy. We attempt to contribute to the broader debate about how best to fund coverage for those outside the formal sector by unpacking some of these issues and pointing to the empirical evidence needed to shed even further light on appropriate funding mechanisms for universal health systems.SUMMARY:The Ghanaian debate on OTPP is related to one of the most important challenges facing low- and middle-income countries seeking to achieve a universal health care system. It is critical that there is more extensive debate on the advantages and disadvantages of alternative funding mechanisms, supported by a solid evidence base, and with the policy objective of universal coverage providing the guiding light.
  • Thumbnail Image
    Item
    Open Access
    Active purchasing mechanisms of private healthcare services: experiences of public and private purchasers in Kenya
    (2019) Chuma, Benson; Orgill, Marsha
    There has been growing global attention to Universal Health Coverage (UHC) and countries across the world have placed achievement of UHC amongst their top policy priorities. UHC is defined as ensuring that all citizens can access relevant health services whenever they need care in a manner that ensures they are not exposed to financial hardship. Health financing systems are critical to achieving UHC- one of the building blocks of a health system, health financing is concerned with the mobilization, accumulation and allocation of funds to cover the needs of a population. The purpose of a health financing system is to make funding available, set the right incentives to health care providers and to ensure all individuals have access to effective public and personal health services. A health financing system has three inter related functions; revenue collection, pooling and purchasing which all need to work together for achievement of UHC. Purchasing is defined as the allocation of pooled funds to providers in exchange for medical services. Purchasing can be passive (whereby purchasers simply pay bills presented by providers) or strategic (whereby purchasers continuously apply evidenced based decisions and processes when allocating funds to providers to maximize value). Many countries aiming to achieve UHC have prioritized shifting from passive to strategic purchasing as part of their health financing system reforms. Literature shows evidence that implementation of strategic purchasing can contribute to achieving UHC by: aligning funding and incentives with promised health services to promote access; linking transfer of funds to providers to performance with the goal of promoting quality in service delivery; and enhancing equity in resource distribution. Implementation of strategic purchasing mechanisms is however not a straight forward process as providers can use various sources of power such as: monopoly and bargaining capacity; some provider payment mechanisms such as fee-for-service; and information asymmetry to resist the adoption of strategic purchasing mechanisms. Providers are likely to resist implementations of those mechanisms that they perceive will shift too much of the risk of providing care to them or will erode their economic gains. Purchasers also have sources of power they can use to influence implementation such as: institutional regulatory authority; monopsony and bargaining authority; and some provider payment mechanisms such as capitation. Power in this study is defined as a relation between two parties whereby party A is said to have power over party B to the extent that A can get B to do something that B would not have otherwise done. Kenya has in the past decade formulated and implemented various policies towards achieving UHC, including reforming some of its purchasing functions. An example is the introduction of capitation (a provider payment mechanism) for private providers, by the public purchaser National Hospital Insurance Fund (NHIF). Private purchasers have, as part of strategic purchasing, intervened in clinical decision-making processes amongst private providers as a way of managing costs and improving quality. Existing literature shows public and private purchasers in Kenya are faced with multiple challenges when implementing strategic purchasing mechanisms such as lack of technical expertise, poor planning and resistance from some providers. This study explored the implementation of strategic purchasing mechanisms by NHIF and private purchasers amongst private providers in Kenya to understand the role of various sources of power in influencing implementation outcomes (acceptability and adoption) in order to contribute to work on how to implement strategic purchasing. Private providers in Kenya play a significant role in provision of care and over 40% of facilities in Kenya are privately owned. We employed a multiple case study design. The first case focused on implementation of capitation by the public purchaser NHIF. The second case focused on the implementation of select strategic purchasing mechanisms by private purchasers including intervening in clinical decision-making processes, use of preauthorization and use of specialists for second opinions amongst others. In total eight interviews were completed and eighteen documents(including newspapers articles, documents from websites, and provider-purchaser contracts) were included as data sources. Each case was analysed individually using thematic analysis, after which a cross case analysis was completed. Our findings show that in the first case of the NHIF purchaser, NHIF used its regulatory authority to gazette and hence dictate the capitation rate to providers. NHIF also used its monopsony to convince providers that there would be significant economic gains from the capitation model as NHIF had a huge number of beneficiaries. However, some of the large providers used their monopoly and bargaining capacity to walk away from the scheme as they still commanded significant market share even without the NHIF capitation business as they felt the proposed capitation rate was too low. In the second case, private purchasers used contracts as a source of power to give them some authority to control prices of services and ensure providers adhered to strategic purchasing mechanisms such as use of preauthorization processes. Some private providers on the other hand used various sources of power to resist implementation such as information asymmetry to by-pass some of the documentation requirements set by the private purchasers. Some providers also used monopoly and fee-for service payment mechanisms to dictate prices of services to purchasers. Some private providers did however willingly adopt some of the strategic purchasing mechanisms namely: preauthorization processes and use of step-down facilities as they felt these minimized the risk of unpaid claims. Across the two cases, NHIF seemed to have had relatively more power over providers compared to private purchasers. For example, NHIF gazetted the capitation rates and did not revise them despite strong opposition from some of the large private providers, whilst private purchasers complained that some of the large private providers always had their way by dictating prices of their services to the private purchasers. Whilst there have been a growing number of recent studies touching on strategic purchasing in Kenya, few of them have focused on the role of power and/or implementation of strategic purchasing in Kenya. This study focused on how various sources of power for providers and purchasers can affect implementation of strategic purchasing in order to provide insight into the implementation of strategic purchasing mechanisms. The study found that private providers can use their various sources of power to resist adoption of strategic purchasing mechanisms they do not deem acceptable; some mechanism are however deemed acceptable and are willingly adopted. The study also highlights that purchasers can use their sources of power to influence adoption of strategic purchasing amongst providers. The study hopes to provide insight to policy makers and purchasers on the need to consider the role of power when implementing strategic purchasing mechanisms and to plan accordingly. One general lesson on implementation includes the importance of early communication and dialogue when implementing strategic purchasing mechanisms.
  • Thumbnail Image
    Item
    Open Access
    Additional costs of FAS and PFAS learners in the classroom: An estimate for public primary schools in the Western Cape
    (2018) Makin, Emma; London, Leslie; Sinanovic, Edina
    Background: The Western Cape province of South Africa has the highest recorded prevalence rates of Fetal Alcohol Spectrum Disorders (FASD) in the world. In the last decade rates of fetal alcohol syndrome (FAS) and partial fetal alcohol syndrome (PFAS) prevalence of 68.0 - 89.2 per 1000 (May et al., 2007), 67.2 per 1000 (Urban et al., 2008), and 59.3 - 91.0 per 1000 (May et al., 2013) have been published after research was conducted in towns in the Western Cape (WC). Educating learners with FASD is a challenge as a result of the large range of cognitive impairments associated with heavy prenatal alcohol exposure. Determining a burden of cost to the education system may be one way to motivate for the development of prevention and intervention strategies. Methods: I designed questionnaires that were distributed to the educator and principal of a cohort of learners including learners with FAS and PFAS. Data were collected on educational impacts of variables associated with educator time use. Additional costs as a result of the use of educator's time by learners with FAS/PFAS were scaled up using risk differences and published statistics to reflect a cost burden to the WC Education Department. Results: The additional cost burden of disruptions caused by learners with FAS and PFAS for the WC Education Department is USD 7,010,166 in educator time for one academic year. The additional burden for learners with FAS/PFAS requiring additional assistance with lesson content to the WC is USD 5,754,885 in educator time for one academic year. The additional cost burden of public primary school learners with FAS/PFAS who had repeated a year of schooling was USD 3,876,565 in educator time based on 2012 salaries. Conclusions: These findings indicate that there is a large burden of cost to the education system when educator time is viewed as an economic input in education. Efforts need to be directed towards prevention programs to reduce the prevalence of learners with FAS/PFAS in the classroom. Educator training programs must be created to ensure that educators are equipped to manage the challenges posed by learners with FAS/PFAS in the classroom.
  • Thumbnail Image
    Item
    Open Access
    Alcohol addiction treatment in Cape Town: Exploratory investigation of the public-private mix
    (2010) Fleming, Laura; Sinanovic, Edina
    Public health and safety are compromised by the effects of alcohol addiction. Some of the consequences include transmission of infectious diseases, disproportionate use of medical and social services, traffic accidents, and street crimes. Additionally, when dealing with alcohol addiction, many expenses are incurred by public services such as the criminal justice system, emergency medical care centers, foster home placement centers, employee assistance programs and family violence centers. The clinical and economic benefits of addiction treatment are therefore clear. The aim of this study was to investigate Cape Town's alcohol addiction treatment center public-private mix and to determine quality of care and access. Document review and semi-structured interviews were the methods used. Provider reporting on quality of care and the limited number of sites interviewed were the main research limitations. Nevertheless, the thesis reached its objectives and contributed to the limited information on alcohol addiction treatment public-private mix, quality of care and access in South Africa. It is notable that there were few differences in the quality of care reported by public, public-private mix, private registered and private unregistered facilities. Quality of care was found to be good across sectors. Public and public-private mix facilities provided superior access in terms of income. Private facilities had the shortest wait-time. Geographic access was a pronounced issue for the poor population that resides in the Southern suburbs, far from affordable primary care alcohol addiction treatment services. Both horizontal and vertical inequities were identified in terms of access to primary care alcohol addiction treatment services in the Cape Town metropole. A strong case is made for involving more of the private sector in public-private partnerships in order to scale up alcohol addiction treatment within the South African setting. This will allow quality of care to be maintained while improving access.
  • No Thumbnail Available
    Item
    Open Access
    An analysis of the user fee policy for health care in Eritrea
    (1998) Asbu, Eyob Zere; McItyre, Di
    The recent upsurge in the interest about financing government health services through user charges has necessitated the conducting of country-specific policy studies in order to monitor the implementation of user fees. This helps to achieve the espoused benefits of the policy and minimize any potential untoward effects. This study was conducted with the objectives of assessing the Eritrean user fee policy that was decreed in February 1996, at all stages from the design to its implementation and the interim effects on revenue generation, efficiency, equity, quality and utilization of services. Primary and secondary data were collected from patients and providers using questionnaire and interview schedules - structured and unstructured. Both open-ended and closed-ended questions were included and covered such issues as socio-economic and demographic characteristics of the respondent, illness and utilization behaviour, and fees and exemptions. The instruments were pre-tested in a small sample of the target population and administered by trained interviewers who had previous experience in health related research. The primary data collection was limited to the capital city for two reasons: firstly, its easy access given the time constraints and, secondly, as a lion's share of the fee revenue is collected in the capital city, it was felt that a close scrutiny at that level could give a preliminary picture of the system as a whole. Respondents were selected randomly and included 100 outpatients, and 50 each of inpatients and health workers (including support staff). Qualitative and quantitative data analysis was done. Descriptive statistics and multivariate regression techniques were employed using the Epi-info and micro-TSP software packages. It was found that the policy, which was an update of a pre-existing one was launched against the background of a favourable macro-economic, political and health sector climate. Fees reduced utilization at the tertiary hospital but did not bring about the required level of efficiency as they did not signal to patients to use the appropriate cost-effective levels of care and the referral system Fee waivers are found to be infrequent, and the process of proving one's indigence at the local administrations is lengthy, thus adversely affecting equity. The cost-recovery ratio for the system as a whole for 1996 was the highest in Sub-Saharan Africa. However, at the lowest health care units, the health stations, the scheme does not seem viable. In some of them, fees could not even cover the salary of the cash collector. Utilization at the primary care units showed a relative increase after implementation of the fee policy, indicating a possible shift of demand from the hospital which is relatively expensive. Though this is in the desired direction, it has a long way to go as many patients are bypassing the nearby primary care facilities . At the sampled health center, patients' willingness and ability to pay was found to be higher than the current fee level However, for the hospital's services, the willingness to pay for the current quality of services was lower than what is currently charged. The study recommends that, for patients bypassing the appropriate primary level facilities, fee levels at the tertiary referral hospital need to be increased so as to promote efficiency. Fee increases at the health centers in the capital city needs to be considered as well. As equity may not be ensured with the current system of entitlement to fee waivers, it is advisable to do a prospective means test. Proxy indicators of indigence should be developed given the income data constraints that make the income-related assessment more difficult. Furthermore, geographical price discrimination is worth considering as the ability to pay of different communities is likely to vary. The MOH should institute negotiations with the Ministry of Finance to retain the fee revenue collected within the health sector, so as to be able to achieve the espoused benefits of user fee policy. Finally the study recommends that such a study be conducted at a large scale and alternative or complementary options of health financing such as health insurance be examined for their feasibility.
  • Thumbnail Image
    Item
    Open Access
    Analysing costs of a facility-based lay health worker intervention focused on improving health outcomes for HIV positive women and children
    (2014) Zeelie, Jean-Pierre; Sinanovic, Edina
    South Africa is facing a health care worker shortage which is contributing to poor health outcomes, especially in mother-to-child transmission of HIV. In order for Prevention of Mother to Child Transmission (PMTCT) programmes to achieve success, coverage needs to be dramatically increased. This paper aims to provide specifics on the costs of integrating a Lay Health Worker (LHW) into a clinic to improve patient uptake and retention of PMTCT services, in what was previously the Motheo district, Free State.
  • Thumbnail Image
    Item
    Open Access
    Analysing unofficial user fees in government and non-government hospitals in Uganda
    (2003) Sonko, Rita Najjemba; Thomas, Stephen
    Unofficial fees are a common feature in Ugandan health facilities and exist in different forms. This study explores the forms of unofficial fees existing in Ugandan hospitals and compares findings from government and non-governmental hospitals in both rural and urban areas. It also investigates the reasons for or causes of such fees as well as the relationship between unofficial fees and other factors such as quality of care within the hospitals. The overall aim of the study is to analyze the magnitude and impact of unofficial fees on patients' expenditure and thereby make recommendations for improvement in efficiency and equity with regards to out-of-pocket funding. Both qualitative and quantitative interview methods are used to obtain data from service providers and patients in each hospital and a comparison of findings obtained using the two methods is made. The main findings from the study are that unofficial fees are rampant in government hospitals and can be classified into four categories; fees for commodities such as drugs; fees for access to services; fees for services such as laboratory, radiology and surgery and gratuity payments. The latter category is the commonest form reported in non- government hospitals while all the others are rare. Estimates of unofficial fees amount to a significant percentage of patients' expenditure, especially in the cases where surgery and radiology are required especially for rural-based patients. It's also found that most of the patients attending government hospitals pay at least one form of unofficial fees. Unofficial fees were found to be closely associated with poor quality of care in that the latter enhanced an informal economy, which resulted in the fees being charged/paid. The study shows that efficiency and equity (access to quality care and ability to pay) are negatively affected by the practice of collecting unofficial fees. Recommendations for policy makers to address the problem are made as well as suggestions for the best-suited methodology for analysing unofficial fees in the Ugandan context.
  • Thumbnail Image
    Item
    Open Access
    An analysis of adherence & equity in access to TB services in Mitchell's Plain, South Africa
    (2012) Docrat, Sumaiyah; Cleary, Susan
    The control of tuberculosis (TB) in South Africa has fallen short of the targets outlined by the World Health Organization and without improvement; TB is expected to have grave consequences for both the mortality and morbidity of South Africans as well as crippling financial consequences for the public health system. While services in the public sector are free at the point of use, little is known about overall access barriers and their implications for treatment adherence. This paper explores these barriers from the perspective of TB patients enrolled in Directly Observed Treatment, Short-Course (DOTS) in Mitchell's Plain, South Africa. Using a comprehensive framework of access, in-depth interviews were conducted with 334 TB patients across five facilities in Mitchell's Plain, to assess barriers across the dimensions of availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between adherent and non-adherent groups, and between socioeconomic groups were explored using bivariate, multivariate linear and logistic regressions. Among the respondents, 244 (73.05%) met the criteria for adherence (i.e. reported that they had never missed a dose of TB medication) while 90 (26.95%) met the criteria for non-adherence. Marital status, age, birth province, costs of self-care and costs of other providers were found to be significantly associated with adherence (P-values <0.05). There was no significant evidence of inequalities in access by socioeconomic status (all P-values > 0.05). Nonetheless, the results revealed that the poor face increased costs of accessing TB-services, compared to the rich, though this association was not deemed to be significant.
  • Thumbnail Image
    Item
    Open Access
    Analysis of equity in the pattern of health care utilisation in South Africa
    (2009) Olabimpe, Oboirien Kafayat; Okorafor, Okore
    The study seeks to assess South Africa’s health care utilisation pattern in the post apartheid era. This is based on the equity driven policy objectives of the health care system that were meant to have impact on individuals’ health care utilisation patterns. A framework of factors influencing health care utilisation is outlined to explain the determinants of health care utilisation. It gives some insights into the socio-economic and racial differences influencing the use and choice of health care in South Africa. It also attempts to investigate how these factors have changed and whether the pattern of health care utilisation among those with higher need has changed over time.
  • Thumbnail Image
    Item
    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.
  • Thumbnail Image
    Item
    Open Access
    An analysis of the user-free policy for health care in Kenya : is the effort worth it?
    (1999) Mwangi, PK; Thomas, Stephen
    This study analyses the user fee policy for health care in Kenya that was introduced to try and recoup some of the costs incurred in providing care as well as rationalise the use of resources. The study aims to generate policy-related findings that are crucial to MOH policy makers in their attempt to provide quality and affordable care. In particular, factors associated with proper function or malfunction of the user fee policy are discussed. The study focussed on four hospitals located in Central province of Kenya. This province was purposefully chosen for its convenience and its high potential for cost recovery. Equity in health care consumption, efficiency, sustainability and perceived quality of care are reviewed. Both primary and secondary data were used. Quantitative and qualitative data were solicited by way of administering questionnaires. Respondents were divided into two categories: providers (staff) and consumers (patients) of health care. The latter were subdivided into inpatients and outpatients. Each of these categories had a specific questionnaire. Further, an attempt is made to estimate net revenue generated in the year 1997/98 by the facilities under study. Costs associated with fee collection were estimated on monthly basis and then projected for the whole year. There are important findings from the study; though patients are charged higher fees at hospitals than at primary levels in order to bolster the referral system, many patients are bypassing the nearby primary care facilities. This study recommends that bypassing patients should be charged higher fees than referred ones.
  • Thumbnail Image
    Item
    Open Access
    Assessing the barriers to accessing prevention of mother-to-child transmission (PMTCT) services in Marondera Zimbabwe
    (2011) Magaso, Farai Beverley; Cleary, Susan
    Although Zimbabwe has invested in nationwide scale-up of prevention of mother to child transmission (PMTCT) services, high HIV-specific under-five mortality rates continue to be observed. This study aimed to document the potential reasons for low PMTCT uptake by examining factors constraining access to PMTCT services.
  • Thumbnail Image
    Item
    Open Access
    Assessment of essential drug management in the public health facilities in Uganda
    (2007) Nahamya, David; Sinanovic, Edina
    The main aim of the study is to evaluate the management of essential drugs in thepublic health facilities in Uganda. This is a cross-sectional study carried out in the districts of Kampala and Mbale employing both qualitative and quantitative methods. Standard outcome indicators as described in the WHO Operational Package for Monitoring and Assessing the Pharmaceutical Situation in Countries are adapted and used in this study.