Igna Bonfrer

Hypertension in Sub-Saharan Africa: Cross-Sectional Surveys in Four Rural and Urban Communities

Background Cardiovascular disease (CVD) is the leading cause of adult mortality in low-income countries but data on the prevalence of cardiovascular risk factors such as hypertension are scarce, especially in sub-Saharan Africa (SSA). This study aims to assess the prevalence of hypertension and determinants of blood pressure in four SSA populations in rural Nigeria and Kenya, and urban Namibia and Tanzania. Methods and Findings We performed four cross-sectional household surveys in Kwara State, Nigeria; Nandi district, Kenya; Dar es Salaam, Tanzania and Greater Windhoek, Namibia, between 2009–2011. Representative population-based samples were drawn in Nigeria and Namibia. The Kenya and Tanzania study populations consisted of specific target groups. Within a final sample size of 5,500 households, 9,857 non-pregnant adults were eligible for analysis on hypertension. Of those, 7,568 respondents ≥18 years were included. The primary outcome measure was the prevalence of hypertension in each of the populations under study. The age-standardized prevalence of hypertension was 19.3% (95%CI:17.3–21.3) in rural Nigeria, 21.4% (19.8–23.0) in rural Kenya, 23.7% (21.3–26.2) in urban Tanzania, and 38.0% (35.9–40.1) in urban Namibia. In individuals with hypertension, the proportion of grade 2 (≥160/100 mmHg) or grade 3 hypertension (≥180/110 mmHg) ranged from 29.2% (Namibia) to 43.3% (Nigeria). Control of hypertension ranged from 2.6% in Kenya to 17.8% in Namibia. Obesity prevalence (BMI ≥30) ranged from 6.1% (Nigeria) to 17.4% (Tanzania) and together with age and gender, BMI independently predicted blood pressure level in all study populations. Diabetes prevalence ranged from 2.1% (Namibia) to 3.7% (Tanzania). Conclusion Hypertension was the most frequently observed risk factor for CVD in both urban and rural communities in SSA and will contribute to the growing burden of CVD in SSA. Low levels of control of hypertension are alarming. Strengthening of health care systems in SSA to contain the emerging epidemic of CVD is urgently needed.

Introduction Of Performance-Based Financing In Burundi Was Associated With Improvements In Care And Quality

Several governments in low- and middle-income countries have adopted performance-based financing to increase health care use and improve the quality of health services. We evaluated the effects of performance-based financing in the central African nation of Burundi by exploiting the staggered rollout of this financing across provinces during 2006-10. We found that performance-based financing increased the share of women delivering their babies in an institution by 22 percentage points, which reflects a relative increase of 36 percent, and the share of women using modern family planning services by 5 percentage points, a relative change of 55 percent. The overall quality score for health care facilities increased by 45 percent during the study period, but performance-based financing was found to have no effect on the quality of care as reported by patients. We did not find strong evidence of differential effects of performance-based financing across socioeconomic groups. The performance-based financing effects on the probability of using care when ill were found to be even smaller for the poor. Our findings suggest that a supply-side intervention such as performance-based financing without accompanying access incentives for poor people is unlikely to improve equity. More research into the cost-effectiveness of performance-based financing and how best to target vulnerable populations is warranted.

Does the distribution of healthcare utilization match needs in Africa

An equitable distribution of healthcare use, distributed according to peoples needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa (SSA). We examine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries. For almost all countries studied, healthcare utilization is considerably higher among the rich. When decomposing these inequalities we find that wealth is the single most important driver. In 12 of the 18 countries wealth is responsible for more than half of total inequality in the use of care, and in 8 countries wealth even explains more of the inequality than need, education, employment, marital status and urbanicity together. For the richer countries, notably Mauritius, Namibia, South Africa and Swaziland, the contribution of wealth is typically less important. As the bulk of inequality is not related to need for care and poor people use less care because they do not have the ability to pay, healthcare utilization in these countries is to a large extent unfairly distributed. The weak average relationship between need for and use of health care and the potential reporting heterogeneity in self-reported health across socio-economic groups imply that our findings are likely to even underestimate actual inequities in health care. At a macro level, we find that a better match of needs and use is realized in those countries with better governance and more physicians. Given the absence of social health insurance in most of these countries, policies that aim to reduce inequities in access to and use of health care must include an enhanced capacity of the poor to generate income.

The effects of performance-based financing on the use and quality of health care in Burundi: an impact evaluation

Abstract Background Performance-based financing (PBF) has attracted considerable interest from governments and aid agencies in low-income countries as a means to increase productivity and quality of health-care providers. In Africa alone, more than 35 countries are in the process of introducing payment methods that reward performance. The Burundi Government has gradually rolled out PBF across all provinces between 2006 and 2010. Our aim was to evaluate whether this has led to changes in the quantity and quality of health-care services provided. Methods We exploited the staggered rollout of PBF to apply a difference-in-differences approach using data from 2006 (baseline), 2008, and 2010. Cross-sectional data were collected among a random sample of 3200 households and panel data among 75 randomly selected health-care facilities across intervention and control provinces. Findings We found that PBF increased the probability of women delivering in an institution by 21 percentage points (p=0·0001), the probability of using antenatal care by 7 percentage points (p=0·067), and the use of modern family planning services by 5 percentage points (p=0·002). The overall facility quality score as constructed by external audits increased by 46%, but no effect of PBF was found on the quality of care as reported by patients. We also found no effects of PBF on vaccination rates, and the satisfaction with waiting times decreased. There is no strong evidence for unequal effects of PBF across socioeconomic groups. Interpretation The introduction of PBF in Burundi has led to significant increases in mother and child care utilisation and in the quality scores of health-care facilities. Given the rising popularity of this financing strategy, more robust evidence on its effects is warranted. Funding We thank the BMG Innovation fund, the Rotterdam Global Health Initiative, and Cordaid Netherlands for funding this research. EvdP is a Postdoctoral Fellow of the Netherlands Organisation for Scientific Research—Innovational Research Incentives Scheme—Veni project 451-11-03.

The Effects of Ghana’s National Health Insurance Scheme on Maternal and Infant Health Care Utilization

Increasing equitable access to health care is a main challenge African policy makers are facing. The Ghanaian government implemented the National Health Insurance Scheme in 2004 and the aim of this study is to evaluate its early effects on maternal and infant healthcare use. We exploit data on births before and after the intervention and apply propensity score matching to limit the bias arising from self-selection into the health insurance. About forty percent of children had a mother who is enrolled in this insurance. The scheme significantly increased the proportion of pregnancies with at least four antenatal care visits with 7 percentage points and had a significant effect on attended deliveries (10 percentage points). Caesarean sections increased (6 percentage points) and the number of children born from an unwanted pregnancy decreased (7 percentage points). Insurance enrollment had almost no effect on child vaccinations. Among the poorest forty percent of the sample, the effects of the scheme on antenatal care and attended deliveries were similar. However, the effects of the scheme on caesarean sections were about half the size (3 percentage points) and the reduction in unwanted pregnancies was larger (10 percentage points) compared to the effects in the full sample. We conclude that in the first years of operation, the National Health Insurance Scheme had a modest impact on the use of antenatal and delivery care. This is important for other African countries currently introducing or considering a national health insurance as a means towards universal health coverage.

The Impact of Financial Incentives on Early and Late Adopters among U.S. Hospitals: Observational Study

Abstract Objective To examine how hospitals that volunteered to be under financial incentives for more than a decade as part of the Premier Hospital Quality Incentive Demonstration (early adopters) compared with similar hospitals where these incentives were implemented later under the Hospital Value-Based Purchasing program (late adopters). Design Observational study. Setting 1189 hospitals in the USA (214 early adopters and 975 matched late adopters), using Hospital Compare data from 2003 through 2013. Participants 1 371 364 patients aged 65 years and older, using 100% Medicare claims. Main outcome measures Clinical process scores and 30 day mortality. Results Early adopters started from a slightly higher baseline of clinical process scores (92) than late adopters (90). Both groups reached a ceiling (98) a decade later. Starting from a similar baseline, just below 13%, early and late adopters did not have significantly (P=0.25) different mortality trends for conditions targeted by the program (0.05% point difference quarterly) or for conditions not targeted by the program (−0.02% point difference quarterly). Conclusions No evidence that hospitals that have been operating under pay for performance programs for more than a decade had better process scores or lower mortality than other hospitals was found. These findings suggest that even among hospitals that volunteered to participate in pay for performance programs, having additional time is not likely to turn pay for performance programs into a success in the future.

Health shocks, coping strategies and foregone healthcare among agricultural households in Kenya

ABSTRACT Risks are a central part of life for households in low-income countries and health shocks in particular are associated with poverty. Formal mechanisms protecting households against the financial consequences of shocks are largely absent, especially among poor rural households. Our aim is to identify the relative importance of health shocks and to explore factors associated with coping behaviour and foregone care. We use a cross-sectional survey among 1226 randomly selected agricultural households in Kenya. In our sample, illness and injury shocks dominate all other shocks in prevalence. Almost 2% of households incurred catastrophic health expenditure in the last year. Using a probit model we identified the main coping strategies associated with facing a health shock: (1) use savings, (2) sell assets and (3) ask for gifts or loans. One in five households forewent necessary care in the last 12 months. We conclude that health shocks pose a significant risk to households. Implementing pre-payment or saving mechanisms might help protect households against the financial consequences of ill health. Such mechanisms, however, should take into account the competing shocks that agricultural households face, making it almost impossible to reserve a share of their limited resources for the protection against health shocks only.

Voluntary health insurance in Nigeria: Effects on takers and non-takers

Interventions aiming to simultaneously improve financial protection and quality of care may provide an important avenue towards universal health coverage. We estimate the effects of the introduction of the Kwara State Health Insurance program in Nigeria on not only the insured but also the uninsured. A subsidized voluntary low cost health insurance was offered by a private insurer as well as a quality upgrade in selected health care facilities. Using propensity score matching and panel data collected in 2009 and 2011 (n = 3509), we find that, for the insured, the program increased health care utilization (36 percent, p < 0.000) and reduced out of pocket expenditure (63 percent, p < 0.000). However, the uninsured in the area with upgraded facilities did not increase their care utilization and even spent less on health care, which is problematic given that 67 percent of the population in the treatment area did not take up the insurance. Our findings suggest that while voluntary health insurance combined with investments in health care supply can increase health care use and financial protection among those that take up the insurance, attention should be paid to potential unintended effects on the - typically sizeable- group of people who do not enroll in the insurance.