Steffen Flessa

Community health insurance in sub-Saharan Africa: what operational difficulties hamper its successful development?

In recent years, a number of reviews have generated evidence on the potential of community health insurance (CHI) to increase access to care and offer financial protection against the cost of illness for poor people excluded from formal insurance systems. Field experience, however, shows that in sub‐Saharan Africa (SSA), a series of operational difficulties still hampers the successful development of CHI, yielding negative effects on potential progress towards increased access to care and improved financial protection. Through a careful assessment of the existing literature, including peer‐reviewed articles, books, consultancy reports, and manuscripts from international organizations, we produce an analytical review of such difficulties. Our aim is to provide policy makers with the necessary knowledge on the problems at stake and with policy propositions to offset such problems, strengthening CHI and enhancing its role within SSA health systems. Our review of the literature reveals that the major difficulties currently faced by CHI in SSA are operational in nature and cluster around five areas: (i) lack of clear legislative and regulatory framework; (ii) low enrolment rates; (iii) insufficient risk management measures; (iv) weak managerial capacity; and (v) high overhead costs. Consequently, our review calls for appropriate policy interventions, specifically: (i) greater commitment towards the development of adequate legislation in support of CHI; (ii) increasing uptake of measures to expand equitable enrolment; (iii) the adoption of adequate risk management measures in all schemes; (iv) substantial investments from host countries as well as from sponsoring agencies to improve managerial capacity; and (v) collective efforts to contain overhead costs.

Use of discrete-event simulation to evaluate strategies for the prevention of mother-to-child transmission of HIV in developing countries

HIV/AIDS affects over 40 million people worldwide, and more than 70% of these people live in Africa. Mother-to-child transmission of HIV accounts for over 90% of all HIV infections in children under the age of 15 years. However, implementing HIV prevention policies in Africa is extremely difficult because of the poor medical and socio-economic infrastructure. In this paper, we present a discrete-event simulation model that evaluates the relative benefits of two potentially affordable interventions aimed at preventing mother-to-child transmission of HIV, namely anti-retroviral treatment at childbirth and/or bottlefeeding strategies. The model uses rural Tanzanian data and compares different treatment policies. Our results demonstrate that strategic guidelines about breastfeeding are highly dependent on the assumed increase in infant mortality due to bottlefeeding, the efficacy of anti-retroviral treatment at childbirth, and the maternal health stage. The cost of averted infections, though low by Western standards, may represent significant obstacles to policy implementation in developing countries.

Determinants of household health expenditure on western institutional health care

We try to identify determinants of illness reporting, provider choice and resulting expenditure with different econometric models using data from a representative household panel survey of 800 households in Nouna health district, Burkina Faso, during 2000–2001. The factors “being an adult”, “married”, “illness occurred in rainy season” and “severe illness” significantly increased the magnitude of health expenditure. Compared to malaria, individuals spent more on other infectious diseases, injury and the other disease category. In contrast, people were less likely to spend on chronic illness. An individual who belonged to a household headed by a female, a literate household head and with a higher household expenditure had a significantly positive association with the magnitude of expenditure. Findings from this study can be used for policy implication to improve health system performance in Burkina Faso through enhancing health care utilization.

Cohort profile: Greifswald approach to individualized medicine (GANI_MED)

BackgroundIndividualized Medicine aims at providing optimal treatment for an individual patient at a given time based on his specific genetic and molecular characteristics. This requires excellent clinical stratification of patients as well as the availability of genomic data and biomarkers as prerequisites for the development of novel diagnostic tools and therapeutic strategies. The University Medicine Greifswald, Germany, has launched the “Greifswald Approach to Individualized Medicine” (GANI_MED) project to address major challenges of Individualized Medicine. Herein, we describe the implementation of the scientific and clinical infrastructure that allows future translation of findings relevant to Individualized Medicine into clinical practice.Methods/designClinical patient cohorts (N > 5,000) with an emphasis on metabolic and cardiovascular diseases are being established following a standardized protocol for the assessment of medical history, laboratory biomarkers, and the collection of various biosamples for bio-banking purposes. A multi-omics based biomarker assessment including genome-wide genotyping, transcriptome, metabolome, and proteome analyses complements the multi-level approach of GANI_MED. Comparisons with the general background population as characterized by our Study of Health in Pomerania (SHIP) are performed. A central data management structure has been implemented to capture and integrate all relevant clinical data for research purposes. Ethical research projects on informed consent procedures, reporting of incidental findings, and economic evaluations were launched in parallel.

Efficiency of primary care in rural Burkina Faso. A two-stage DEA analysis

BackgroundProviding health care services in Africa is hampered by severe scarcity of personnel, medical supplies and financial funds. Consequently, managers of health care institutions are called to measure and improve the efficiency of their facilities in order to provide the best possible services with their resources. However, very little is known about the efficiency of health care facilities in Africa and instruments of performance measurement are hardly applied in this context.ObjectiveThis study determines the relative efficiency of primary care facilities in Nouna, a rural health district in Burkina Faso. Furthermore, it analyses the factors influencing the efficiency of these institutions.MethodologyWe apply a two-stage Data Envelopment Analysis (DEA) based on data from a comprehensive provider and household information system. In the first stage, the relative efficiency of each institution is calculated by a traditional DEA model. In the second stage, we identify the reasons for being inefficient by regression technique.ResultsThe DEA projections suggest that inefficiency is mainly a result of poor utilization of health care facilities as they were either too big or the demand was too low. Regression results showed that distance is an important factor influencing the efficiency of a health care institutionConclusionsCompared to the findings of existing one-stage DEA analyses of health facilities in Africa, the share of relatively efficient units is slightly higher. The difference might be explained by a rather homogenous structure of the primary care facilities in the Burkina Faso sample. The study also indicates that improving the accessibility of primary care facilities will have a major impact on the efficiency of these institutions. Thus, health decision-makers are called to overcome the demand-side barriers in accessing health care.

Comparative cost analysis of insecticide-treated net delivery strategies: sales supported by social marketing and free distribution through antenatal care

Insecticide-treated nets (ITNs) are effective in substantially reducing malaria transmission. Still, ITN coverage in sub-Saharan Africa (SSA) remains extremely low. Policy makers are concerned with identifying the most suitable delivery mechanism to achieve rapid yet sustainable increases in ITN coverage. Little is known, however, on the comparative costs of alternative ITN distribution strategies. This paper aimed to fill this gap in knowledge by developing such a comparative cost analysis, looking at the cost per ITN distributed for two alternative interventions: subsidized sales supported by social marketing and free distribution to pregnant women through antenatal care (ANC). The study was conducted in rural Burkina Faso, where the two interventions were carried out alongside one another in 2006/07. Cost information was collected prospectively to derive both a financial analysis adopting a providers perspective and an economic analysis adopting a societal perspective. The average financial cost per ITN distributed was US

Modelling the effectiveness of financing policies to address underutilization of children's health services in Nepal

8.08 and US

Basing care reforms on evidence: the Kenya health sector costing model.

7.21 for sales supported by social marketing and free distribution through ANC, respectively. The average economic cost per ITN distributed was US

Assessing the efficiency of rural health centres in Burkina Faso: an application of Data Envelopment Analysis

4.81 for both interventions. Contrary to common belief, costs did not differ substantially between the two interventions. Due to the districts ability to rely fully on the use of existing resources, financial costs associated with free ITN distribution through ANC were in fact even lower than those associated with the social marketing campaign. This represents an encouraging finding for SSA governments and points to the possibility to invest in programmes to favour free ITN distribution through existing health facilities. Given restricted budgets, however, free distribution programmes are unlikely to be feasible.

Prospective association of low serum total testosterone levels with health care utilization and costs in a population-based cohort of men

OBJECTIVE To estimate the price responsiveness of utilization of formal childrens health-care services in Nepal and to use this information to model the impact on utilization of subsidies or increases in user fees. METHODS A total of 8112 individual observations (of children aged < 15 years) from 2847 households in 274 communities were obtained from the 1996 Nepal Living Standards Survey. A logit model was applied to determine the net impact of price on a parent or caregivers decision to seek care for a given instance of illness. The models coefficients were used to calculate the price responsiveness of utilization decisions. FINDINGS Parents or caregivers reported that 9.7% of children (788/8112) had been ill or injured in the previous month. Parents reported that they had sought care in 566 (71.8%) of these cases; care was most frequently sought from public providers. The price elasticity of demand for childrens health-care services in the formal sector was estimated at -0.16. As prices rise, the demand curve exhibits continuous and declining price elasticity. Overall, a 100% subsidy of user fees would increase current utilization rates by 56%, while a 100% increase in fees would lead to a drop in utilization of only 12%. The differential in utilization across income groups was substantial after changes in fees were implemented. CONCLUSION While the effect of price on the utilization of childrens health-care services in Nepal is statistically significant, the size of the impact is modest. Policies to subsidize fees could increase utilization substantially, while fee increases would lead to modest declines in utilization and generate increased revenue.