Eyob Zere

Technical efficiency of district hospitals: Evidence from Namibia using Data Envelopment Analysis

BackgroundIn most countries of the sub-Saharan Africa, health care needs have been increasing due to emerging and re-emerging health problems. However, the supply of health care resources to address the problems has been continuously declining, thus jeopardizing the progress towards achieving the health-related Millennium Development Goals. Namibia is no exception to this. It is therefore necessary to quantify the level of technical inefficiency in the countries so as to alert policy makers of the potential resource gains to the health system if the hospitals that absorb a lions share of the available resources are technically efficient.MethodAll public sector hospitals (N = 30) were included in the study. Hospital capacity utilization ratios and the data envelopment analysis (DEA) technique were used to assess technical efficiency. The DEA model used three inputs and two outputs. Data for four financial years (1997/98 to 2000/2001) was used for the analysis. To test for the robustness of the DEA technical efficiency scores the Jackknife analysis was used.ResultsThe findings suggest the presence of substantial degree of pure technical and scale inefficiency. The average technical efficiency level during the given period was less than 75%. Less than half of the hospitals included in the study were located on the technically efficient frontier. Increasing returns to scale is observed to be the predominant form of scale inefficiency.ConclusionIt is concluded that the existing level of pure technical and scale inefficiency of the district hospitals is considerably high and may negatively affect the governments initiatives to improve access to quality health care and scaling up of interventions that are necessary to achieve the health-related Millennium Development Goals. It is recommended that the inefficient hospitals learn from their efficient peers identified by the DEA model so as to improve the overall performance of the health system.

Equity in health and healthcare in Malawi: analysis of trends

BackgroundGrowing scientific evidence points to the pervasiveness of inequities in health and health care and the persistence of the inverse care law, that is the availability of good quality healthcare seems to be inversely related to the need for it in developing countries. Achievement of the Millennium Development Goals is likely to be compromised if inequities in health/healthcare are not properly addressed.ObjectiveThis study attempts to assess trends in inequities in selected indicators of health status and health service utilization in Malawi using data from the Demographic and Health Surveys of 1992, 2000 and 2004.MethodsData from Demographic and Health Surveys of 1992, 2000 and 2004 are analysed for inequities in health/healthcare using quintile ratios and concentration curves/indices.ResultsOverall, the findings indicate that in most of the selected indicators there are pro-rich inequities and that they have been widening during the period under consideration. Furthermore, vertical inequities are observed in the use of interventions (treatment of diarrhoea, ARI among under-five children), in that the non-poor who experience less burden from these diseases receive more of the treatment/interventions, whereas the poor who have a greater proportion of the disease burden use less of the interventions. It is also observed that the publicly provided services for some of the selected interventions (e.g. child delivery) benefit the non-poor more than the poor.ConclusionThe widening trend in inequities, in particular healthcare utilization for proven cost-effective interventions is likely to jeopardize the achievement of the Millennium Development Goals and other national and regional targets. To counteract the inequities it is recommended that coverage in poor communities be increased through appropriate targeting mechanisms and effective service delivery strategies. There is also a need for studies to identify which service delivery mechanisms are effective in the Malawian context.

Technical efficiency of peripheral health units in Pujehun district of Sierra Leone: a DEA application

BackgroundThe Data Envelopment Analysis (DEA) method has been fruitfully used in many countries in Asia, Europe and North America to shed light on the efficiency of health facilities and programmes. There is, however, a dearth of such studies in countries in sub-Saharan Africa. Since hospitals and health centres are important instruments in the efforts to scale up pro-poor cost-effective interventions aimed at achieving the United Nations Millennium Development Goals, decision-makers need to ensure that these health facilities provide efficient services. The objective of this study was to measure the technical efficiency (TE) and scale efficiency (SE) of a sample of public peripheral health units (PHUs) in Sierra Leone.MethodsThis study applied the Data Envelopment Analysis approach to investigate the TE and SE among a sample of 37 PHUs in Sierra Leone.ResultsTwenty-two (59%) of the 37 health units analysed were found to be technically inefficient, with an average score of 63% (standard deviation = 18%). On the other hand, 24 (65%) health units were found to be scale inefficient, with an average scale efficiency score of 72% (standard deviation = 17%).ConclusionIt is concluded that with the existing high levels of pure technical and scale inefficiency, scaling up of interventions to achieve both global and regional targets such as the MDG and Abuja health targets becomes far-fetched. In a country with per capita expenditure on health of about US

Inequities in utilization of maternal health interventions in Namibia: implications for progress towards MDG 5 targets

7, and with only 30% of its population having access to health services, it is demonstrated that efficiency savings can significantly augment the governments initiatives to cater for the unmet health care needs of the population. Therefore, we strongly recommend that Sierra Leone and all other countries in the Region should institutionalise health facility efficiency monitoring at the Ministry of Health headquarter (MoH/HQ) and at each health district headquarter.

Inequities in skilled attendance at birth in Namibia: A decomposition analysis

BackgroundInequities in the utilization of maternal health services impede progress towards the MDG 5 target of reducing the maternal mortality ratio by three quarters, between 1990 and 2015. In Namibia, despite increasing investments in the health sector, the maternal mortality ratio has increased from 271 per 100,000 live births in the period 1991-2000 to 449 per 100,000 live births in 1998-2007. Monitoring equity in the use of maternal health services is important to target scarce resources to those with more need and expedite the progress towards the MDG 5 target. The objective of this study is to measure socio-economic inequalities in access to maternal health services and propose recommendations relevant for policy and planning.MethodsData from the Namibia Demographic and Health Survey 2006-07 are analyzed for inequities in the utilization of maternal health. In measuring the inequities, rate-ratios, concentration curves and concentration indices are used.ResultsRegions with relatively high human development index have the highest rates of delivery by skilled health service providers. The rate of caesarean section in women with post secondary education is about seven times that of women with no education. Women in urban areas are delivered by skilled providers 30% more than their rural counterparts. The rich use the public health facilities 30% more than the poor for child delivery.ConclusionMost of the indicators such as delivery by trained health providers, delivery by caesarean section and postnatal care show inequities favoring the most educated, urban areas, regions with high human development indices and the wealthy. In the presence of inequities, it is difficult to achieve a significant reduction in the maternal mortality ratio needed to realize the MDG 5 targets so long as a large segment of society has inadequate access to essential maternal health services and other basic social services. Addressing inequities in access to maternal health services should not only be seen as a health systems issue. The social determinants of health have to be tackled through multi-sectoral approaches in line with the principles of Primary Health Care and the recommendations of the Commission on Social Determinants of Health.

Using data envelopment analysis to measure the extent of technical efficiency of public health centres in Ghana

BackgroundThe fifth Millennium Development Goal (MDG5) aims at improving maternal health. Globally, the maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. During the same period, MMR in sub-Saharan Africa decreased from 870 to 640. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. In Namibia, there are significant inequities in births attended by skilled providers that favour those that are economically better off. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers.MethodsNamibia Demographic and Health Survey data of 2006-07 are analysed for the causes of inequities in skilled birth attendance using a decomposable health concentration index and the framework of the Commission on Social Determinants of Health.ResultsAbout 80.3% of the deliveries were attended by skilled health providers. Skilled birth attendance in the richest quintile is about 70% more than that of the poorest quintile. The rate of skilled attendance among educated women is almost twice that of women with no education. Furthermore, women in urban areas access the services of trained birth attendant 30% more than those in rural areas. Use of skilled birth attendants is over 90% in Erongo, Hardap, Karas and Khomas Regions, while the lowest (about 60-70%) is seen in Kavango, Kunene and Ohangwena. The concentration curve and concentration index show statistically significant wealth-related inequalities in delivery by skilled providers that are to the advantage of women from economically better off households (C = 0.0979; P < 0.001).Delivery by skilled health provider by various maternal and household characteristics was 21 percentage points higher in urban than rural areas; 39 percentage points higher among those in richest wealth quintile than the poorest; 47 percentage points higher among mothers with higher level of education than those with no education; 5 percentage points higher among female headed households than those headed by men; 20 percentage points higher among people with health insurance cover than those without; and 31 percentage points higher in Karas region than Kavango region.ConclusionInequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel. This clearly implies that addressing inequalities in access to child delivery services should not be confined to the health system and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.

Inequities in maternal and child health outcomes and interventions in Ghana

BackgroundData Envelopment Analysis (DEA) has been used to analyze the efficiency of the health sector in the developed world for sometime now. However, in developing economies and particularly in Africa only a few studies have applied DEA in measuring the efficiency of their health care systems.MethodsThis study uses the DEA method, to calculate the technical efficiency of 89 randomly sampled health centers in Ghana. The aim was to determine the degree of efficiency of health centers and recommend performance targets for the inefficient facilities.ResultsThe findings showed that 65% of health centers were technically inefficient and so were using resources that they did not actually need.ConclusionThe results broadly point to grave inefficiency in the health care delivery system of public health centers and that significant amounts of resources could be saved if measures were put in place to curb the waste.

Equity in reproductive and maternal health services in Bangladesh.

BackgroundWith the date for achieving the targets of the Millennium Development Goals (MDGs) approaching fast, there is a heightened concern about equity, as inequities hamper progress towards the MDGs. Equity-focused approaches have the potential to accelerate the progress towards achieving the health-related MDGs faster than the current pace in a more cost-effective and sustainable manner. Ghanas rate of progress towards MDGs 4 and 5 related to reducing child and maternal mortality respectively is less than what is required to achieve the targets. The objective of this paper is to examine the equity dimension of child and maternal health outcomes and interventions using Ghana as a case study.MethodsData from Ghana Demographic and Health Survey 2008 report is analyzed for inequities in selected maternal and child health outcomes and interventions using population-weighted, regression-based measures: slope index of inequality and relative index of inequality.ResultsNo statistically significant inequities are observed in infant and under-five mortality, perinatal mortality, wasting and acute respiratory infection in children. However, stunting, underweight in under-five children, anaemia in children and women, childhood diarrhoea and underweight in women (BMI < 18.5) show inequities that are to the disadvantage of the poorest. The rates significantly decrease among the wealthiest quintile as compared to the poorest. In contrast, overweight (BMI 25-29.9) and obesity (BMI ≥ 30) among women reveals a different trend - there are inequities in favour of the poorest. In other words, in Ghana overweight and obesity increase significantly among women in the wealthiest quintile compared to the poorest. With respect to interventions: treatment of diarrhoea in children, receiving all basic vaccines among children and sleeping under ITN (children and pregnant women) have no wealth-related gradient. Skilled care at birth, deliveries in a health facility (both public and private), caesarean section, use of modern contraceptives and intermittent preventive treatment for malaria during pregnancy all indicate gradients that are in favour of the wealthiest. The poorest use less of these interventions. Not unexpectedly, there is more use of home delivery among women of the poorest quintile.ConclusionSignificant Inequities are observed in many of the selected child and maternal health outcomes and interventions. Failure to address these inequities vigorously is likely to lead to non-achievement of the MDG targets related to improving child and maternal health (MDGs 4 and 5). The government should therefore give due attention to tackling inequities in health outcomes and use of interventions by implementing equity-enhancing measure both within and outside the health sector in line with the principles of Primary Health Care and the recommendations of the WHO Commission on Social Determinants of Health.

Equity in health care in Namibia: developing a needs-based resource allocation formula using principal components analysis

BackgroundThe target date for achieving the Millennium Development Goals (MDGs) is now closer than ever. There is lack of sufficient progress in achieving the MDG targets in many low- and middle-income countries. Furthermore, there has also been concerns about wide spread inequity among those that are on track to achieve the health-related MDGs. Bangladesh has made a notable progress towards achieving the MDG 5 targets. It is, however, important to assess if this is an inclusive and equitable progress, as inequitable progress may not lead to sustainable health outcomes. The objective of this study is to assess the magnitude of inequities in reproductive and maternal health services in Bangladesh and propose relevant recommendations for decision making.MethodsThe 2007 Bangladesh demographic and health survey data is analyzed for inequities in selected maternal and reproductive health interventions using the slope and relative indices of inequality.ResultsThe analysis indicates that there are significant wealth-related inequalities favouring the wealthiest of society in many of the indicators considered. Antenatal care (at least 4 visits), antenatal care by trained providers such as doctors and nurses, content of antenatal care, skilled birth attendance, delivery in health facility and delivery by caesarean section all manifest inequities against the least wealthy. There are no wealth-related inequalities in the use of modern contraception. In contrast, less desired interventions such as delivery by untrained providers and home delivery show wealth-related inequalities in favour of the poor.ConclusionsFor an inclusive and sustainable improvement in maternal and reproductive health outcomes and achievement of MDG 5 targets, it essential to address inequities in maternal and reproductive health interventions. Under the government’s stewardship, all stakeholders should accord priority to tackling wealth-related inequalities in maternal and reproductive health services by implementing equity-promoting measures both within and outside the health sector.

National health financing policy in Eritrea: a survey of preliminary considerations

BackgroundThe pace of redressing inequities in the distribution of scarce health care resources in Namibia has been slow. This is due primarily to adherence to the historical incrementalist type of budgeting that has been used to allocate resources. Those regions with high levels of deprivation and relatively greater need for health care resources have been getting less than their fair share. To rectify this situation, which was inherited from the apartheid system, there is a need to develop a needs-based resource allocation mechanism.MethodsPrincipal components analysis was employed to compute asset indices from asset based and health-related variables, using data from the Namibia demographic and health survey of 2000. The asset indices then formed the basis of proposals for regional weights for establishing a needs-based resource allocation formula.ResultsComparing the current allocations of public sector health car resources with estimates using a needs based formula showed that regions with higher levels of need currently receive fewer resources than do regions with lower need.ConclusionTo address the prevailing inequities in resource allocation, the Ministry of Health and Social Services should abandon the historical incrementalist method of budgeting/resource allocation and adopt a more appropriate allocation mechanism that incorporates measures of need for health care.