Natasha Palmer

Health financing to promote access in low income settings—how much do we know?

In this article we outline research since 1995 on the impact of various financing strategies on access to health services or health outcomes in low income countries. The limited evidence available suggests, in general, that user fees deterred utilisation. Prepayment or insurance schemes offered potential for improving access, but are very limited in scope. Conditional cash payments showed promise for improving uptake of interventions, but could also create a perverse incentive. The largely African origin of the reports of user fees, and the evidence from Latin America on conditional cash transfers, demonstrate the importance of the context in which studies are done. There is a need for improved quality of research in this area. Larger scale, upfront funding for evaluation of health financing initiatives is necessary to ensure an evidence base that corresponds to the importance of this issue for achieving development goals.

Performance-based payment: some reflections on the discourse, evidence and unanswered questions

Performance-based payment (PBP) is increasingly advocated as a way to improve the performance of health systems in low-income countries. This study conducted a systematic review of the current literature on this topic and found that while it is a popular term, there was little consensus about the meaning or the use of the concept of PBP. Significant weaknesses in the current evidence base on the success of PBP initiatives were also found. The literature would be strengthened by multi-disciplinary case studies that present both the advantages and disadvantages of PBP, influential factors for success, and more details about the projects from which this evidence is drawn. Where possible, data from control facilities where PBP is not being implemented would be an important addition. This paper suggests a further agenda for research, including assessing optimal conditions for implementation of PBP schemes in less developed health systems, the impact of adopting measures of performance as targets, and the requirements for monitoring PBP adequately.

The use of private-sector contracts for primary health care: theory, evidence and lessons for low-income and middle-income countries

Contracts for the delivery of public services are promoted as a means of harnessing the resources of the private sector and making publicly funded services more accountable, transparent and efficient. This is also argued for health reforms in many low- and middle-income countries, where reform packages often promote the use of contracts despite the comparatively weaker capacity of markets and governments to manage them. This review highlights theories and evidence relating to contracts for primary health care services and examines their implications for contractual relationships in low- and middle-income countries.

Fever treatment and household wealth: the challenge posed for rolling out combination therapy for malaria.

Objective  To investigate the variation in malaria parasitaemia, reported fever, care seeking, antimalarials obtained and household expenditure by socio‐economic status (SES), and to assess the implications for ensuring equitable and appropriate use of antimalarial combination therapy.

A new face for private providers in developing countries: what implications for public health?

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.

Constraints to implementing the essential health package in Malawi.

Increasingly seen as a useful tool of health policy, Essential or Minimal Health Packages direct resources to interventions that aim to address the local burden of disease and be cost-effective. Less attention has been paid to the delivery mechanisms for such interventions. This study aimed to assess the degree to which the Essential Health Package (EHP) in Malawi was available to its population and what health system constraints impeded its full implementation. The first phase of this study comprised a survey of all facilities in three districts including interviews with all managers and clinical staff. In the second and third phase, results were discussed with District Health Management Teams and national level stakeholders, respectively, including representatives of the Ministry of Health, Central Medical Stores, donors and NGOs. The EHP in Malawi is focussing on the local burden of disease; however, key constraints to its successful implementation included a widespread shortage of staff due to vacancies but also caused by frequent trainings and meetings (only 48% of expected man days of clinical staff were available; training and meetings represented 57% of all absences in health centres). Despite the training, the percentage of health workers aware of vital diagnostic and therapeutic approaches to EHP conditions was weak. Another major constraint was shortages of vital drugs at all levels of facilities (e.g. Cotrimoxazole was sufficiently available to treat the average number of patients in only 27% of health centres). Although a few health workers noted some improvement in infrastructure and working conditions, they still considered them to be widely inadequate. In Malawi, as in similar resource poor countries, greater attention needs to be given to the health system constraints to delivering health care. Removal of these constraints should receive priority over the considerable focus on the development and implementation of essential packages of interventions.

What do we mean by rigorous health-systems research?

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The costs of changing national policy: lessons from malaria treatment policy guidelines in Tanzania

Objective  To document the cost incurred by the Tanzanian government by changing the policy on first‐line treatment of malaria, from chloroquine to sulfadoxine–pyrimethamine.

Assessing the effects of removing user fees in Zambia and Niger

Objectives This study aims to overcome some of the limitations of previous studies investigating the effects of fee removal, by looking at heterogeneity of effects within countries and over time, as well as the existence of spillover effects on groups not targeted by the policy change. Methods Using routine district health services data before and after recent abolitions of user charges in Zambia and Niger, we examine the effects of the policy change on the use of health services by different groups and over time, using an interrupted timeseries design. Results Removing user fees for primary health care services in rural districts in Zambia and for children over five years old in Niger increased use of services by the targeted groups. The impact of the policy change differed widely across districts, ranging from 112% and 1194% in Niger to 239% and 1108% in Zambia. Eighteen months after the policy change, some of these effects had been eroded. There was evidence that abolishing user fees can both have positive and negative spillover effects. Conclusion These results highlight the importance of paying attention to implementation challenges and monitoring the effects of policy reforms which are often more mixed and complicated that they appear. The comparison of these reforms in two countries also sheds light on the potentially different ways in which free care can be used as a tool to improve access.

Availability of essential medicines in Ethiopia: an efficiency‐equity trade‐off?

Objective  To investigate the availability and cost of essential medicines in health centres in rural Ethiopia, and to explore if the fee waiver system protects patients from having to pay for medicines.