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ecuringPHCforall:thefoundationformakingprogressonUHCinAfrica

KempinskiHotelGoldCoastCity(Accra)

11th–14thMarch2019

5th AfHEA Conference – 2019

ProgrammeandAbstractBook

[2011]

[2019]

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AfHEA 5th Conference (Accra 2019) Securing PHC for all: the foundation for making progress on UHC in Africa

The5thAfHEAScientificConference isorganized inpartnershipswith theMinistryofHealthof theRepublic of Ghana, the World Health Organization (WHO), the Ghana Health Service (GHS), theSchool of Public Health of the University of Ghana (SPH), and the Center for Health Systems andPolicyResearch(CHESPOR).

Wegratefullyacknowledgefinancialassistancefortheconferencereceivedfromourpartners

Fifth Conference of the African Health Economics and Policy Association (AfHEA)

“Securing PHC for all: the foundation for making progress on UHC in Africa”

Published by AfHEA © 2019

Cover Page: Knights Advertising Limited

Compilation of the programme and abstracts: Pascal Ndiaye (Mabouya Solutions)

The scientific contents of the abstracts are entirely the responsibility of their authors. The opinions expressed do not necessarily reflect the positions of AfHEA.

For further information, kindly write to: [email protected]

Visit the AfHEA web site for updates on its activities: www.afhea.org


TableofcontentAgenda.................................................................................................................................18

Oralpresentations..........................................................................................................20ParallelSession1–Organizedsession.....................................................................21

OS01–InstitutionalizationofFinancialProtectionMonitoringinAfrica...21Analysisoffinancialriskprotectioninhealth.CaseoftheDemocraticRepublicofCongo................................................................................................................................................................22Analysisofhealth-relatedfinancialriskprotectionofhouseholdinCôted’Ivoirefrom2008to2015.................................................................................................................................................23TrendofcatastrophichealthexpenditureandtheirimpactontheimpoverishmentofMauritanianhouseholdsbetween2008and2014.......................................................................24DynamicsofcatastrophicandimpoverishmentexpendituresinBurkinaFaso:ananalysisofdeterminants..........................................................................................................................25ImpactofOutofPocketPaymentsonFinancialProtectionIndicatorsinasettingwithnouserfees:ThecaseofMauritius.....................................................................................................25

ParallelSession1-Oralpresentations....................................................................27

Parallelsession1:UniversalHealthCoverage(UHC)–progressandchallenges...........................................................................................................................27DetermininglevelsofsatisfactionwithrolesofHMOsamongbeneficiariesofsocialhealthinsuranceschemeinEnugu,SoutheastNigeria...............................................................27ThechallengesofachievinguniversalfinancialriskprotectioninEnuguState,SouthEastNigeria....................................................................................................................................................28Movingtowardsuniversalhealthcoverage:Theneedforastrengthenedplanningprocess.............................................................................................................................................................28HealthInsuranceforInformalSectorWorkersinCôted'Ivoire:LessonsLearnedfromtheImplementationoftheMCMA........................................................................................................29RevitalizingPrimaryHealthCaretoAchieveUniversalHealthCoverageinMauritius29CrunchTime:thetransformationalUniversalHealthCoverageagendaforZambia.....30PolitickingwithHealthCareandItsImplicationforTheAttainmentofUniversalHealthCoverage...........................................................................................................................................31Achievinguniversalhealthcoverageinnigeriathroughhealthfinancing.........................31

ParallelSession1-2Privatesector,PPPandcontractingout..........................32GoverningPublicPrivatePartnershipstoadvanceUHCobjectives:ExperiencesfromGovernment-PrivateNot-for-ProfitcontractualrelationshipsinUganda........................32Trustmeifyoucan!RealistinsightsonhowmistrustundermineseffectivePublicPrivateEngagementandstrategiestoaddressitinWest-Africa...........................................33TheNigerianPBFApproachtoContractingUsingStateActors.............................................34FaithbasedhealthprovidersarelessaffordabletoaccessforPLHIV,acomparativestudyfromNorthTanzania.....................................................................................................................34Mobilizingresourcesfromtheprivatesectorfortargetedhealthinvestmentsusingevidencefromcostingassessments....................................................................................................35

ParallelSession1-3(Costeffectiveness:casestudies).......................................36CostsandsustainabilityofanovelCommunityHealthWorkersprogrammeinimprovingMotherandChildHealthinNigeria..............................................................................36ExaminingtheaffordabilityofhypertensioncareinKenyanhospitals:acostanalysisfromthepatient’sperspective..............................................................................................................37


CostsofaddingrapidsyphilistesttoexistingantenatalservicesattheprimaryhealthcarelevelinBurkinaFaso:amicrocostingapproachforprenataldiagnosis.....38Economicburdenoftype2diabetesmellituscomplicationsamongpatientsintheeasternregionofGhana:Adescriptivecross-sectionalcost-ofillnessstudy...................39CostinganalysisofsaltiodinefortificationinEthiopia:preliminaryresults....................39AssessingtheDeterminantsofCostEfficiencyofPrimaryHealthCareFacilitiesinGhana:ALatentClassStochasticFrontierAnalysis.....................................................................40Anextendedcost-effectivenessanalysisoftheAIDSTrustFundinUganda....................41

Parallelsession1-4AccesstoHIV-AIDSservices.................................................42Discontinuationofanti-retroviraltreatment:anempiricalanalysisofthedeterminants.................................................................................................................................................42EffectiveHIVCareandSupportInterventionsinNigeria:Arights-basedapproach....43DeterminantsofregulardemandforantiretroviraltherapyinTogo..................................44FactorsassociatedwithlowuptakeofHIVearlyinfantdiagnosisamongtheHIVexposedinfant:Towards90-90-90targetof2020inHarareCity,Zimbabwe................45ToWhatExtentCanTaskShiftingReduceTheHIVPrevalenceintheMSMPopulation,Malawi..............................................................................................................................................................45Antiretroviraldispensinggroupsasameasuretoimproveadherence:cost-effectivenessanalysisinZambia..........................................................................................................46

Parallelsession1-5Accesstomaternalhealthservices....................................47FactorsassociatedwithlateuseofpostnatalfirstassistanceinahealthfacilityafterhomedeliveryinIvoryCoast.................................................................................................................47Assessingthecostofmaternalpostpartumservices,beforeandafterinterventionsinBurkinaFaso.................................................................................................................................................47AvailabilityofemergencyobstetricandneonatalcareinWestAfrica:thecaseofIvoryCoast.................................................................................................................................................................48Socialandeconomicdeterminantsofunder-fivemortalityinsub-SaharanAfrica:thecaseofSenegal..............................................................................................................................................49ReachingRuralReproductiveWomeninKintampo,GhanawithFamilyPlanning:EvidencefromtheEquityTool...............................................................................................................50SocioeconomicinequalitiesinmaternalhealthinZimbabwe:thecaseofskilledbirthattendanceandantenatalcoverage....................................................................................................50AccesstomaternalhealthservicesunderthefreematernalhealthpolicyintheKassena-NankanamunicipalityofGhana.........................................................................................51

ParallelSession1-6Economicevaluationofhealthprogrammes..................52EconomicevaluationoftheFamilyHealthTeamatthePrimaryHealthCareUnithealthfacilitiesinAddisAbaba:CostingandCostEffectivenessAnalysis.........................52CostEffectivenessandBudgetImpactofFondaparinuxforthetreatmentofAcuteCoronarySyndrome(ACS)inNon-STandSTElevationMyocardialInfarctionpatientsintheSouthAfricanpublichealthsystem........................................................................................53EconomicburdenofglaucomaonpatientsattendingtwohealthfacilitiesinTemaMetropolis,Ghana.......................................................................................................................................54Economicimplicationsofdelayedreviewofreimbursementpricesoftraceressentialmedicinesonaccreditedhealthfacilitiesinejisu-juabenmunicipality,Ghana...............54

Parallelsession1-7Dataformanagementandpolicymaking........................55Whatdoweneedtoknow?Datasourcestosupportevidence-baseddecisionsusinghealthtechnologyassessmentinGhana...........................................................................................55MeasuringwellbeingusingtheWomen’sCapabilitiesIndexamongstwomeninvolvedinhigh-risksexualbehaviourinKampala,Uganda,.....................................................................56CollectinghealthfacilityandpatientmedicineinformationthroughtelephoneinterviewsinKenya:Avalidationstudy...........................................................................................57


TheroleofInformationTechnologyinmaximizingPHCHRHGovernanceinKadunaState,Nigeria.................................................................................................................................................58

ParallelSession2.............................................................................................................59

Organizedsession............................................................................................................59

OS02–TowardSystematicApproachesforAddressingEthics&EquityConsiderationsinHealthTechnologyAssessment..............................................59

ParallelSession2.............................................................................................................62

Oralpresentations..........................................................................................................62ParallelSession2-1UniversalHealthCoverageUHCMonitoringandevaluation..........................................................................................................................62SupplysidereadinessforUniversalHealthCoverage:AssessingtheserviceavailabilityanddepthofservicesinremoteandfragiledistrictofIndia...................................................62Doesaffordabilitymatter?ExaminingthetrendsandpatternsinhealthcareexpenditureinIndia...................................................................................................................................63TheGlobalFinancingFacilityInvestmentCase-aPHCapproachcontributingtoMadagascar’sUHCinitiative...................................................................................................................63AssessingtheweaknessofanexistingdiseasesprogrammeshouldbeagoodwayforstrengtheningthehealthsystemstowardUniversalHealthCoverage:caseofMauritius.........................................................................................................................................................64MonitoringprogresstowardsattainmentoffinancialriskprotectioninUganda..........65

ParallelSession2-2EquityinHealth........................................................................66Correlatesof`PublicAwarenessofPatientRightsandResponsibilitiesinHealthcareDeliveryintheSagnariguDistrict,Ghana.........................................................................................66IncludingtheExcluded:StakeholdersStrategiestoImproveAccesstoHealthForTheSociallyExcludedInNigeria...................................................................................................................67Assessingsocioeconomicinequalitiesinmaternalhealthcareovertime;evidencefromfourAfricancountries...............................................................................................................................67HorizontalinequityandinequalityinhealthcareutilisationinSouthAfrica:AlongitudinalanalysisusingtheNationalIncomeDynamicSurvey(NIDS)........................68Socioeconomicinequalitiesinthemultipledimensionsofaccess:ThecaseofSouthAfrica................................................................................................................................................................69Leavingnoonebehind:AssessingsocioeconomicinequalitiesinthepursuitofUniversalHealthCoverageinGhana..................................................................................................69Healthinequalityassessment:reproductive,maternalandchildhealthinUganda.....70

ParallelSession2-3Communitybasedhealthinsurance..................................71AReviewofCommunity-basedHealthInsuranceSchemes(CBHIS):LessonsfromNigeriaandGhana.......................................................................................................................................71CanCommunityBasedSavingGroups(CBSGs)usherinCommunityHealthInsurance(CHI)inruralareas?AcasestudyofthreedistrictsinEasternUganda.............................72Assessmentofthefeasibilityofcommunity=basedhealthinsurance(CBHI)schemeforfinancialriskprotectioninthreeafricancountries:asystematicreview..........................72MutualhealthinsuranceandfinancingofhealthexpensesamongfamiliesinGourocountryinIvoryCoast...............................................................................................................................73EffectofCommunity-BasedHealthInsuranceonUtilisationofPreventiveHealthServicesinruralUganda..........................................................................................................................74

ParallelSession2-4Drugs&Medicines...................................................................74Theeffectsofmedicinesavailabilityandstock-outsonhousehold’sutilizationofhealthcareservicesacrosssixdistrictcouncilsinDodomaregion,Tanzania.................74


Consumptionandexpenditureonanti-diabeticdrugsfrom2016to2017bybeneficiariesofahealthinsurancemutualinIvoryCoast........................................................75AssessingtheRationaluseofMedicines(RUM)incommunitypharmaciesinGhana.76TrainingAnambraStateprimaryhealthworkersonmedicinemanagementandprovisionofmanagementtools:stepstowardshealthsystemsstrengtheningfordeliveringprimaryhealthcare..............................................................................................................77MedicinesAvailabilityandAccessibilityunderPerformance-BasedFinancing(PBF):LessonsfromThreeNigeriaStateHealthInvestmentProject(NSHIP)ImplementingStates................................................................................................................................................................78PanafricanRegulationofthePharmaceuticalIndustryviatheMedicinesAgency........79Spatio-temporalvariationsintheuseofantimalarialdrugsinCôted'Ivoirefrom2016to2017.............................................................................................................................................................79WhatarethepotentialhealthgainsandpolicyimplicationsoftheWorldHealthOrganizationrecommendationonpopulation-widesaltreductionby2025?.................80

ParallelSession2-5EconomicsofImmunization,malaria,TBandHIV-AIDS................................................................................................................................................81MathematicalmodelingofdruginventoryforsustainablepharmacymanagementinUganda.............................................................................................................................................................81Dossierd’investissementpourl’accélérationduprogrammedevaccinationplusauBénin(2018-2023).....................................................................................................................................81Impactandcosteffectivenessofrotavirusvaccinationin73Gavicountries...................82Impactandcost-effectivenessofRSVmaternalimmunizationinGavicountries..........83

ParallelSession2-6Economicevaluationofhealthprogrammes..................84Cross-countrycomparisonofthecostsofhealthcareservices,andthecostdrivers,atcross-borderlocationsinKenya,Rwanda,UgandaandTanzania.........................................84ExaminingtheeconomicimpactofType2DiabetesandtheriskofcatastrophicexpenditureamongadefinedpatientpopulationattendingatertiaryhealthcarefacilityinNigeria:ImplicationsforUniversalHealthCoverage..............................................85UsingSocialReturnonInvestment(SROI)MethodologytoAssessValue-for-MoneyofPublicHealthInterventionsinAfrica:AnExampleofanEvaluativeSROIofEmergencyObstetricCareTraininginKenya.........................................................................................................85EconomicEvaluationofacommunitydeliveredprojectforleprosycasedetectioninNorthernNigeria.........................................................................................................................................86

ParallelSession2-7AidandInternationalhealthfinancing............................87PoliticalEconomyofDevelopmentAidforHealthinPost-GDPRebasedNigeria:implicationsforfinancinguniversalhealthcoverage.................................................................87TheimpactofaidonhealthoutcomesinUganda.........................................................................88Foreignaidandthehealthsector:acasestudyfromthePalestiniannationalauthority.............................................................................................................................................................................88AnanalysisofDomesticandDonorFinancingforMaternal,Neo-natalandChildHealthinSub-SaharanAfrica................................................................................................................................89

ParallelSession3.............................................................................................................91Organizedsession............................................................................................................91

OS03–StrengtheningCapacityforTeachingandLearningofHealthPolicyandSystemsResearch(HPSR)andHealthEconomicsinAfrica:PracticalIssuesforEducatorsandLearners............................................................................91TeachingandLearningacrossmultiplefieldsforHealthPolicyandSystemsResearch(HPSR)andHealthEconomics(HE)...................................................................................................92Usingaudio-visualaidsinteachingandlearningHealthPolicyandSystemsResearch(HPSR)andHealthEconomics(HE)...................................................................................................93


LeadershipdevelopmentandreflectivepracticeinHealthSystemsandPolicyResearch(HPSR).........................................................................................................................................94HowdoEducatorsSupportEachOtherinAfricaforHPSRandHEEducationandwhatpedagogicalapproachcanweusetoimprovecurriculum.......................................................95

OS04–ApproachesforachievingUniversalHealthCare:PolicyPerspectivesfromAfricaandAsia.............................................................................95OS05–Howcanhealthsystemsbeshapedtosustainablyaddressthematernalhealthneedsofthemostvulnerableandunder-servedpopulations?......................................................................................................................96Whatmotivatesprimaryhealthcareworkerstoperformwellinresource-limitedsettings?InsightsfromrealistevaluationofhealthsystemsstrengtheninginNigeria96Howsecureareprimaryhealthcarefacilitiestoprovideservicesforthevulnerablepopulation?:ExperienceofprovidersinamaternalandChildHealthprogramme......97CostsandsustainabilityofanovelCommunityHealthWorkersprogrammeinimprovingMotherandChildHealthinNigeria..............................................................................98

OS06–Strengtheninghealthsystemsthroughtheapplicationofhealthfinancingprogressmatrices:countryexperience................................................99PAPER1:AnoverviewoftheHealthFinancingProgressMatrix:asystematicapproachtoassessingpolicydevelopmentsatthecountrylevel............................................................100PAPER2:StrengtheninghealthfinancinginTanzania:priorityactionsidentifiedbytheProgressMatrices.............................................................................................................................100PAPER3:StrengtheninghealthfinancinginUganda:priorityactionsidentifiedbyProgressMatrices....................................................................................................................................101

OS07–Strategicpurchasingforuniversalhealthcoverage:theroleofalignedmixedproviderpaymentsystems...........................................................102Presentation1:AGuideandkeyquestionstoassessaMixedProviderPaymentSystem(MPPS)..........................................................................................................................................102Presentation:CasestudyfromBurkinaFaso...............................................................................102Presentation3:CountrycasestudyfromEgypt.........................................................................103Presentation3:CountrycasestudyfromMalawi......................................................................104

OS08–IsapercapitapaymentsystemaviablestrategicpurchasingoptionforassuringuniversalaccesstoPrimaryHealthCareinGhana:Whathavewelearnedovertimeandwhatisthewayforward.........................................105Abstracts1:ContextandProcessofthedesignandImplementationofaCapitationPilotinAshantiRegion,GhanafromtheperspectiveofthePPM-TSC:Aninsiderview...........................................................................................................................................................................105Abstract2:Theriseandfallofmaternityservicesandmedicinesascomponentsinthecapitationbasket:.....................................................................................................................................106Abstract3:EffectofapercapitapaymentsystemonutilizationandclaimsexpenditureundertheNHIS...............................................................................................................107

(OS09)ParallelSession3–TheinfluenceofCulturalPracticesinthespreadofDiseases:thecaseoffarNorthofCameroon...................................107(OS10)ParallelSession3–Howagent-basedmodellingcanhelphealthcarepolicyandplanning...............................................................................108Agent-basedmodellingforhealtheconomicevaluationsandhealthcarepolicydecisions......................................................................................................................................................108RobustAnalyticsforMalariaPolicy:WhatistheRoleforIndividual-BasedModels?109Healthcareprioritysettinginsub-SaharanAfrica:whatdoesagent-basedmodelshavetooffer?..............................................................................................................................................109


ParallelSession4–Organizedsession..................................................................110

OS11–Sounddecisionmaking–adevelopmentpartnershipforUHC.....110ParallelSession4-Oralpresentations.................................................................111

ParallelSession4-1Healthfinancingassessments..........................................111DocountriesthatspendrelativelymoreonPHCcomparedtohigherlevelcarehavebetterhealthoutcomesthanthosethatspendrelativelymoreonhigherlevelcarecomparedtoPHC?....................................................................................................................................111OptionsforlongtermsustainablefinancingofHIVandAIDSresponsesinUganda:resultsofastakeholdersurvey..........................................................................................................112InstitutionalizationofNationalHealthAccounts:ExperienceofMauritiusinshapingandimplementingpoliciesandstrategies....................................................................................112ExaminingmultiplefundingflowstopublichealthcarefacilitiesinKenyaandtheirinfluenceonproviderbehaviorandservicedelivery..............................................................113HealthcarefinancinginNigeria:Asystematicreviewassessingtheevidenceoftheimpactofhealthinsuranceonprimaryhealthcaredelivery................................................114IsthereanyFiscalSpaceforHealth?LessonslearntfromresourcemappingexerciseinMalawi...........................................................................................................................................................114WhatarethehealthfinancingneedsofmobilepopulationsinEastAfrica?ThecaseoflongdistancetruckdriversinEastAfrica.....................................................................................115DoesPredictabilityofMultipleFundingFlowstoHealthcareFacilitiesinfluenceProviderbehaviour?LessonsfromCasestudiesinEnuguStateNigeria........................116Out-of-pockethealthcarepaymentintheeraofnationalhealthinsurance:Afive-yearstudyofprimaryhealthfacilitiesinsevendistrictsofnorthernGhana...........................117

ParallelSession4-2Maternalandchildhealthcare1.....................................117HealthdemographicsandtrendsinchildandyouthhealthindicatorsinIvoryCoastfrom2012to2016...................................................................................................................................117CommunityWallsofGoodHealth:Community-ledmonitoringandadvocacytoolstoimprovematernalandchildhealthoutcomesinruralGhana..............................................118AnEvaluationoftheMaternalandChildHealthProjectoftheSubsidyReinvestmentandEmpowermentProgramme(SUREP)....................................................................................119Preferencesofpregnantwomenattendingantenatalcareregardingpreventionofmother-to-childHIVtransmissionservicedeliverymodelsinEthiopia:DiscreteChoiceExperiment.................................................................................................................................................120

ParallelSession4-3Resultandperformancebasedfinancing.....................121TowardsaconstructivereflectiononPerformance-BasedFinancing:perspectivesofimplementingactorsinSub-SaharanAfrica.................................................................................121Performance-basedFinancingandExternalCross-Audit:atoolimprovingthegovernanceapproachinDRCongo..................................................................................................121HealthSectorApplicationofProgrammeBasedBudgeting–EarlyLessonsfromKenya..........................................................................................................................................................................122UnderstandingthecontextualandimplementationfactorsconstrainingtheresultsofaPerformanceBasedFinancingschemeextendedtomalnutritioninHealthcentersofBurundi—insightsfromamixedmethodresearchinBurundi..........................................123UsingthePerformanceBasedFinancing(PBF)conditionalgrantstoincreasedomesticresourceallocationtohealthsectorwithintheKenyancontextofdevolution............124PBFinSierraLeone:TheWayForward.........................................................................................125UsingthePerformanceBasedFinancing(PBF)conditionalgrantstoincreasedomesticresourceallocationtohealthsectorwithintheKenyancontextofdevolution............125

ParallelSession4-4Purchasingofservices........................................................126


AnalysisofthemixedsystemofpaymenttermsandconditionsforserviceprovidersinthecontextofthestrategicprocurementofhealthservicesinBurkinaFaso..........126Attributedevelopmentandlevelselectionforachoiceexperimentoncapitationandfee-for-servicemechanisms................................................................................................................127HealthcarepurchasinginKenya:experiencesofhealthcareproviderswithcapitationandfee-for-serviceproviderpaymentmechanisms.................................................................128AcriticalanalysisofhealthcarepurchasingarrangementsinKenya:Acasestudyofthecountydepartmentsofhealth.....................................................................................................129Strategicprocurementofbasichealthcare:whatroleforplanneddemand(mutualhealthinsurance)intheUHCprocessinComoros?..................................................................129ImpactoftheRBFapproachonthetechnicalviabilityofmutualhealthinsurance-focusonstreamliningcare...................................................................................................................130StrategicpurchasinginhealthcareinKenya:ExaminingreformsbytheNationalHospitalInsuranceFund.......................................................................................................................131

ParallelSession4-5Userfees-removalandexemptions..............................132Co-existenceofHighOutofPocketpaymentsforhealthandfreehealthcareinpublichealthfacilitiesaparadoxforconsolidatingprimaryhealthcareinMauritius............132Aligningpublicfinancialmanagementsystemandfreehealthcarepolicies:lessonsfromafreematernalandchildhealthcareprogrammeinNigeria.....................................133Costimplicationsfreematernalpolicies:LessonsfromboththeglobeandimplementationinKenya.....................................................................................................................133FactorsexplainingcatastrophichealthspendinginCôted'Ivoire.....................................134EffectOfPublicHealthExpenditureOnCatastrophicHealthExpenditureInSub-SaharanAfrica...........................................................................................................................................135EquityinOutofPocketHealthCareExpenditureinTurkey:AnAnalysisof2004–2013Years..................................................................................................................................................135

ParallelSession4-6EvaluatingPHCperformance1........................................136AssessmentoftheoperationalcapacityoffirstcontacthealthinstitutionsinthemanagementofmalariainCôted'Ivoire........................................................................................136UniversalHealthCoveragePrimaryHealthCareSelf-AssessmentinSudan.................137CommunityParticipationinPrimaryHealthCareDelivery:AMixedMethodsStudyoftheCommunity-basedHealthPlanningandServicesprogrammeintheBuilsaNorthDistrict,Ghana...........................................................................................................................................138OperationalizationofhealthdistrictsasastrategyforrevitalisingprimaryhealthcareinIvoryCoast.............................................................................................................................................139

ParallelSession4-7Governanceandaccountability1....................................140Allhands-ondeck:lessonslearnedfromeffectivemulti-stakeholderengagementtostrengthenprimaryhealthcareinSenegal...................................................................................140WhoisMoreCorrupt:IdentifyingtheperpetratorsofabsenteeismamonghealthworkersinNigeria...................................................................................................................................141IdentifyingandprioritisinghealthsectorcorruptioninNigeria........................................142Useofhealthfacilitycommitteestoimprovehealthsystemgovernanceandaccountability:InstitutionalizationandSustainabilityissuesinEnuguStateNigeria..........................................................................................................................................................................142GovernancechallengesandsolutionswithinafreeMaternalandChildHealth(FMCH)servicesprogramme:Re-visitingtheSURE-PMCHprogrammeinNigeria..................143


OS12–TeachingHealthEconomics–aLMICfocus..........................................144

ParallelSession5-Oralpresentations.................................................................147Parallelsession5-1–HealthFinancingandpolicy...........................................147


EvaluationofPublicPolicyforPopulationWideHealthReformsinSub-SaharanAfrica;ACriticalReviewofSaltReductionPoliciesinSouthAfrica&Nigeria............................147Macro-economicdeterminantsofpublicexpenditureforhealthinsub-saharianafricancountries.......................................................................................................................................148FiscalSpaceforHealthatDecentralizedLevel:ThePotentialImpactofFiscalArrangementsinKenya.........................................................................................................................148Demonstratingthebenefitsofinvestinginrehabilitation:evidencesfrom3Sub-SaharanAfricancountriesstudies....................................................................................................149FiscalPoliciesforHealth.......................................................................................................................150UtilizationoffreematernalhealthcareservicesundertheNationalHealthInsuranceSchemeinruralGhana:ResultsfromtheKintampoHealthandDemographicSurveillanceSystem(2005–2015).................................................................................................151FinancingUniversalHealthCover(CMU):asingleagencyfundedbyataxonproducts..........................................................................................................................................................................151PHCandHealthcarefinancingbyincometaxrevenues,andinequalitiesreductioninCôted'Ivoire...............................................................................................................................................152AreviewoftheincidenceanddeterminantsofcatastrophichealthexpenditureinNigeria:implicationsforuniversalhealthcoverage.................................................................153

ParallelSession5-2Maternalandchildhealthcare2.....................................154SocioeconomiccorrelatesandthedemandforchildhealthcareservicesinGhana,KenyaandZambia...................................................................................................................................154Kenyanwomen’spreferencesforplaceofdelivery:AcomparativeDiscreteChoiceExperimentbetweenEmbakasiNorthsub-CountyandNaivashasub-County,Kenya...........................................................................................................................................................................154Howsecureareprimaryhealthcarefacilitiestoprovideservicesforthevulnerablepopulation?:ExperienceofprovidersinamaternalandChildHealthprogramme...155FinancingFamilyPlanningActivitiesUsingDomesticResourcesatDistrictLevelinMalawi...........................................................................................................................................................156FactorsAffectingAccessandUtilizationofChildHealthCareinNigeria........................157InvestingintheMidwiferyprofessioninCameroon:astrategicconditiontostrengthenmaternalhealthcoverage.............................................................................................157WomenEmpowerment,SpousalViolenceandMaternalandChildHealthSeekingBehaviors.....................................................................................................................................................158

ParallelSession5-3Healthbehavioursandperceptions...............................158AreNHISclientsservedinferiorandsub-standardmedicines?:PerceptionsandfactorsthatinfluencemedicinesaccessandqualityundertheNHISinGhana............158PerceivedbarriersandfacilitatorstoadherencetoantiretroviraltherapyamongpersonslivingwithHIVintheUpperEastRegion.....................................................................159AwarenessofLassaFeverVirusDiseaseSurvey........................................................................160Exploringtheperceivedrisksandbenefitsofheroinuseamongyoungpeople(18-24)andserviceprovidersinMauritius:AQualitativeStudy........................................................161RedZoneParamedics–afilmabouttheeverydayexperiencesofanambulancecrewinCapeTown:Usingfilmtodevelopbottom-upsolutionstoaddressviolence................161Perceivedbarrierstoaccessingfemalecommunityhealthvolunteers’servicesamongstethnicminoritywomeninNepal:aqualitativestudy...........................................162Perspectivesofmalesonutilizationofhealthservices:importantstakeholderinachievinghouseholdsustainablehealth........................................................................................163PatientsatisfactionandclinicalqualityinSouthAfrica’spublicprimaryhealthcare164OutreachasATooltoPreventChronicDiseasesandCreateDemandfortheirCareinUganda:Cost-EffectivenessandCommunityPerceptions.....................................................165VoicesfromtheMiddlebeltofGhanaonUHCforall–ParticipationandPerceptionsofOlderPersonsonSocialHealthInsuranceProgramutilizingamixedmethodapproach......................................................................................................................................................166


ParallelSession5-4Healthtechnologyassessments.......................................167Healthtechnologyassessmentcapacityatnationallevelinsub-SaharanAfrica:asurveyofstakeholders...........................................................................................................................167Theimpactofmobileclinicsonincreasingaccesstoqualityhealthcare:thecaseofmobilevansoutreachservicesinGhana........................................................................................167StrengtheningHealthTechnologyAssessment(HTA)SystemsforUniversalHealthCoverageinAfrica:HowcanHTAimproveequity,accessandqualityofhealthcareservices?.......................................................................................................................................................168ThePriceImpactsoftheIntroductionofSouthAfrica’sTaxonSugar-SweetenedBeverages....................................................................................................................................................169StrengtheningHealthTechnologyAssessmentSystemsintheGlobalSouth:AComparativeAnalysisoftheHTAjourneysofChina,IndiaandSouthAfrica................170

Parallelsession5-5Mentalhealthissues.............................................................171PromotingAccesstoMentalHealthCareServicesusingcommunitystructuressuchasTraditionalMentalHealthCentersinGhana................................................................................171PromotingAccesstoMentalHealthCareServicesusingcommunitystructuressuchasTraditionalMentalHealthCentersinGhana................................................................................172Subjectivesocialinequalitiesindepression:adecompositionanalysisforSouthAfrica..........................................................................................................................................................................172EconomicburdenandmentalhealthofprimarycaregiversofperinatallyHIVexposedandinfectedadolescentsfromKilifi,Kenya.................................................................................173

ParallelSession5-6EvaluatingPHCperformance2........................................174It’snotenoughtotweakoldmodels:UrbanPHCcallsfornewparadigmsandapproaches..................................................................................................................................................174StrengtheningPrimaryHealthCarefortheProperManagementofTuberculosisinCôted'Ivoire...............................................................................................................................................175CommunityhealthworkersinMali,costsofincludingtheirservicesinthePHC-UHC..........................................................................................................................................................................175THEMATICTRACK:#4CommunityHealthSystems–WhereCommunityNeedsareLocated.........................................................................................................................................................176AssessingHealthSystemsReadinessforPrimaryHealthCareFinancing:LessonsLearnedfromKadunaandNigerState,Nigeria..........................................................................176Implementationprocessandqualityofaprimaryhealthcaresystemimprovementinitiativeinadecentralizedcontext:AretrospectiveappraisalusingtheQualityImplementationFramework...............................................................................................................177ThePHCpolicyinCôted'Ivoire:AnassessmentattheBouafléHealthDistrict...........178

ParallelSession5-7Governanceandaccountability2....................................178PopulationempowermentisoneofthestrategyforstrengtheningprimaryhealthcareinMauritius.................................................................................................................................................178StrengtheningRegulationforPatientSafety:Frontlinestaffs’perceptionsofKenya’sregulatoryreforms..................................................................................................................................179DoesGovernanceImpactUndernutrition:AnIntegratedApproachtoReducingUnderweightinChildrenUnder5years........................................................................................180ProcessofSelectionImprovesMembershipCompositionandRepresentativenessofHorizontalAccountabilityStructuresforPhcStrengthening:CaseStudy0fFourHealthFacilityCommittees.................................................................................................................................181IncreasingfiscalspaceforhealthinMalawi:Moreresourcemobilizationorincreasedabsorptioncapacityofexistingresources?...................................................................................182ImpactoftheregulatoryhealthworkforceinformationsysteminZambia...................183



OS13-PublicfinancialmanagementtowardsbetterPHCandhealthsectoroutputs:BuildinganddisseminatingknowledgeforacceleratedreformsinAfrica.................................................................................................................................184Paper1:Buildingstrongpublicfinancialmanagementsystemstowardsuniversalhealthcoverage:KeybottlenecksandlessonslearnedfromcountryreformsinAfrica..........................................................................................................................................................................184Paper2:Transitioningfrominputs-basedbudgettoprogrambudgetsinthehealthsector:lessonsfromBurkinaFaso....................................................................................................185Paper3:PracticalrealitiesofimplementingprogrambudgetingacrosstheGhanaianhealthsector...............................................................................................................................................186

OS14–AnActivistAgendaforHealthPolicyandSystems(HPS)ResearchandPractiseinAfrica..................................................................................................187OS15–ImplementingBoldReformstowardsFinancingUHCinaDecentralizedEconomy:PoliticalEconomy,Innovations,andProgressinNigeria..............................................................................................................................189

OS16–TranslatingEvidencetoAction:ParticipatoryApproachesforStrengtheningMaternalHealthInterventions...................................................190Implementationprocessandqualityofaprimaryhealthcaresystemimprovementinitiativeinadecentralizedcontext:AretrospectiveappraisalusingtheQualityImplementationFramework...............................................................................................................190AdolescentmotherswanteasyaccesstoantenatalcareservicesintheHohoeMunicipalityofGhana:FindingsfromaParticipatoryActionResearch..........................191AParticipatoryActionResearchforhealthsystembottleneckanalysesinaPreventionofMaternaltoChildTransmissionofHIVprogrammeinNigeria......................................192Themidwivesservicescheme:aqualitativecomparisonofcontextualdeterminantsoftheperformanceoftwostatesincentralNigeriaBackground............................................193

OS17–TheeffectofhumanresourcesmanagementonperformanceinhospitalsinSub-SaharanArica................................................................................193OS18–PromotingaccesstoqualityandresponsivementalhealthcareandservicesinGhana..........................................................................................................194Abstract#1.................................................................................................................................................196ImprovingtheLivesofPersonsSufferingfromMentalIllnessesinGhana:AnImpactAssessmentoftheChristianHealthAssociationofGhana’s(CHAG)IntegratedMentalHealthServices..........................................................................................................................................196Abstract#2.................................................................................................................................................196PromotingQualityAccesstoMentalHealthCareServicesusingcommunitystructuressuchasTraditionalMentalHealthCentersinGhana...............................................................196Abstract#3.................................................................................................................................................197TheRoleoftheGhanaHealthServiceinachievingUniversalHealthCoveragethroughIntegratedMentalHealthServicesinGhana................................................................................197Abstract#4.................................................................................................................................................198TheImpactofOrganizationalSupportindealingwithMentalHealthIssuesintheWorkplaceandatSchoolinGhana–AnAdvocacyCall...........................................................198

OS19–SecuringPHCforallinavoluntaryhealthinsurance:lessonsfromtheNHIA-KOFIHcollaborationinGhana..............................................................199EnhancingenrolmentontotheNHIStoachieveUniversalHealthCoverage:AsurveytoexplorebarriersandenablerstoenrolmentamongNHISmembersintheVoltaRegion..........................................................................................................................................................................200


The“Universal”inUHCandGhana’sNationalHealthInsuranceScheme:policyandimplementationchallengesanddilemmasofalowermiddleincomecountry............201Theexperimenttostimulatevoluntaryenrolmentthroughexpansionofregistrationunitsandintensifyingeducationofmembersatthedistrictoffice....................................202

EconomicsofPublicHealth:ImplicationsforresearchpracticeinAfrica203Incorporatingdemandineconomicevaluationofpublichealthinterventions:casestudyofanaugmentedexercisereferralschemeusingweb-basedbehaviouralsupport..........................................................................................................................................................................203Assessingcosteffectivenessofmultinationalandfactorialtrials:internet-basedtrainingforprimarycarecliniciansonantibioticprescribingforacuterespiratory-tractinfections..........................................................................................................................................204Evidencesynthesisfordecisionmaking:Themethodsormethodologicalissues?Thecaseforwillingness-to-paycriterionvalidityassessments...................................................204

OS21–Sexualreproductivehealthandrights:asmartinvestmenttowardsachievingSDGsby2030..............................................................................................206

ParallelSession7-1Resourceallocation,efficiencyandmanagement1..207AssessingtheEffectofPerformance-BasedFinancing(PBF)onHealthCareQualityinNigeria:ExperiencesfromNigeriaStateHealthInvestmentProject(NSHIP)ImplementingStates...............................................................................................................................207Canperformancescorecardspromotecommunityinvolvementinregulatoryenforcement?AprocessevaluationofaninnovativeregulatoryinterventioninKenya..........................................................................................................................................................................208PatternsandappropriatenessofsurgicalreferralsinMalawi.............................................208Streetlevelbureaucrats:malariainpregnancypolicyimplementationinnineGhanaianhealthfacilities.....................................................................................................................209TowardsprimaryhealthcareforallinGhana:mappingandassessingthecapacityofhealthfacilitiesinCentralregion......................................................................................................210MakingsupervisionSupportiveandSustainableinPrimaryHealthCareServicesinNigeria...........................................................................................................................................................211

ParallelSession7-2NonCommunicablediseases............................................212BarriersandopportunitiesforNCDmanagementinPrimaryHealthCare:Lessonsfromaclinicalworkflowanalysisindiabetesandhypertensionclinics..........................212Socio-economiccorrelateswiththeprevalenceandonsetofdiabetesinSouthAfrica:EvidencefromthefirstfourwavesoftheNationalIncomeDynamicsStudy...............212CostofaccessingdiabeticcareservicesinIgangadistrict,EasternUganda..................213Theeffectsoflifestyleriskfactorsandnon-communicablediseasesonlabourforceparticipationinSouthAfrica...............................................................................................................214Incidence,socio-economicinequalitiesanddeterminantsofcatastrophichealthexpenditurefordiabetescareinSouthAfrica.............................................................................215THEHOUSEHOLDECONOMICIMPACTOFRHEUMATICHEARTDISEASE(RHD)INSOUTHAFRICA..........................................................................................................................................215NCD’sandeconomicoutcomesinSouthAfrica:acohortstudyfortheperiodof2008-2016atindividualandhouseholdlevel.........................................................................................216

ParallelSession7-3Newtrendsanddebatesininternationalhealthfinancing..........................................................................................................................217EvaluationofPerformanceoftheAfricanUnionSupporttoEbolaOutbreakinWestAfrica(ASEOWA)MissioninControllingEbolaVirusDisease(EVD)andRestoringHealthServicesinGuinea,LiberiaandSierraLeone................................................................217UHCthroughPHC:PilotingPreferredPrimaryCareProviderNetworksinGhana....218AnanalysisofdonorfinancingofhumanresourcesforhealthactivitiesandhealthworkermigrationinSub-SaharanAfricancountries...............................................................219


Towardsachievingthehealth-relatedSDGs:theroleofunconditionalcashtransfersinAfrica.............................................................................................................................................................220TheroleofNGOsinhealthsystemsstrengtheningtoachieveUHC–Botswana’sexperiencewithGlobalFundtoFightAIDS,TuberculosisandMalaria...........................220

ParallelSession7-4HumanResourcesforHealth-countryexperiences221Costeffectivenessanalysisoffullytimepaidcommunityhealthworkerinthreeruraldistricts–Tanzania:Rufiji,KilomberoandUlanga...................................................................221PushingbackUniversalHealthCoverage:CausesandconsequencesofabsenteeismofhealthworkersatthePHClevelinNigeria...................................................................................222Asystematicreview:interventionsforimprovingtheretentionofphysiciansworkinginruralareastostrengthenPrimaryHealthCare.....................................................................223InvestmentinhealthhumanresourcesandeconomicgrowthinIvoryCoast..............223Motivationofcommunity-basedhealthagentsinBurkinaFaso:sustainablestrategiesimplemented,andlearntlessons......................................................................................................224

ParallelSession7-5Preferencesandwillingnesstopay................................225AssessmentoftheacceptabilityofCommunityBasedHealthInsuranceasahealthfinancingmechanismandmaximumwillingnesstopayamongsturbanslumdwellersinAbuja,Nigeria.......................................................................................................................................225WillingnesstopayforhealthinsuranceamongcommercialmotorcyclistsinNakawadivision,Kampalacapitalcityauthority,Uganda.......................................................................226Willingnesstopayforcontributoryhealthinsurance:FindingsfromanexploratorystudyinthestateofKaduna,Nigeria...............................................................................................227Caregivers’willingnesstoacceptandpayforHIVandSickleCellScreeningatImmunizationCentersinNigeria......................................................................................................227Patients’willingnesstopayforthetreatmentoftuberculosisinNigeria:exploringownuseandaltruism.......................................................................................................................................228DeterminingpreferencesfordifferentBenefitPackagesandWillingnesstoPayforCommunity-BasedHealthInsuranceamongtheurbanslumdwellersinAbuja,Nigeria..........................................................................................................................................................................229

ParallelSession7-6Healtheconomicstoolsandapproaches1...................229HealthEconomicsanalysisinAfrica:Asystematicreview....................................................229AssessingtheTechnicalEfficiencyofhealthExpendituresinLowandMiddle-IncomeCountries:NewApproachthroughthePartialFrontierAnalysis.......................................230IsenrolmentintoGhana’sNationalHealthInsuranceSchemepro-poororpro-rich?EvidencefromsecondaryanalysisofGhanaLivingStandardSurveyroundsix..........230ExploringtheUsefulnessofDiscreteChoiceExperimentstoExplainPreferences:TheCaseofHIVTestingPreferencesAmongTruckDriversinKenya.......................................231Southafricanmultipledeprivation-concentrationindexquantilesdifferentiatedbycomponentsofsuccessandimpedimenttotuberculosiscontrolprogrammeusingmathematicalmodellinginruralo.r.tambodistricthealthfacilities................................232Thenigerianhealtheconomist’sunplayedroleinsecuringprimaryhealthcareforall..........................................................................................................................................................................233UsingtheEquityTooltoDetermineSocio-EconomicStatusintheKintampoHealthDemographicSurveillanceArea:AFeasibilityStudy...............................................................234EstimatingthedirectmedicalcostsofHelicobacterpylorieradicationtherapyforoutpatientprimarycareinCameroon:implicationsforqualitycareanduniversalhealthcoverage.........................................................................................................................................235

ParallelSession8-1Resourceallocation,efficiencyandmanagement2..236SettingupanadequateinformationsolutiontostrengthenprimaryhealthcareinMauritius......................................................................................................................................................236


Identifyingpriorityhealthsystemstrengtheningactionsthroughaparticipatoryapproachforaddressingnon-communicablediseasecrisisinMauritius.......................237WhoAreWe?TheRoleofTeam,ProfessionalandManagerialRelationshipsinCollectiveLeadershipPracticesinDistrictHospitals,CapeTown,SouthAfrica..........238Tanzanian’srevisionofStandardTreatmentGuidelinesandNationalEssentialMedicinesList............................................................................................................................................239Servicedeliveryplanninginresourceconstrainedsettings:evidencefromNigeria.239TheroleofefficiencygainsinexpandingfiscalspaceforhealthinNigeria...................240

ParallelSession8-2Publichealthresearchissues...........................................241LimitedhealthstatusawarenessandbiasedequityestimatesinLMIC...........................241RiskySexualBehaviourofYouthinRuralAreasofNigeria:ImplicationsforPrimaryHealthCentres...........................................................................................................................................242UtilizationofprimaryhealthcareinNigeria:AquantileregressionanalysisusingtheServiceDeliveryIndicatorsSurveyData........................................................................................242Characterizationof331G/ApolymorphismofRPgeneandidentificationofviraloncogeneHMTVvirusasgeneticmarkersfortheimprovementofbreastcancermanagementinCameroon...................................................................................................................243EvaluatingtheImpactofSouthAfrica’sIdealClinicRealisationProgrammeusingQuasi-ExperimentalMethods.............................................................................................................244Healthstateutilityvaluesamongchildrenandadolescentswithdisabilities:AsystematicReviewandMetaanalysisoftheevidence.............................................................244Outcomesandassociatedfactorsofintegratedcommunitycasemanagementofchildhoodillnessesindawrozone,SouthWestEthiopia.......................................................245UsingInterventionMappingtoDesignandImplementQualityImprovementStrategiesTowardsEliminationofLymphaticFilariasisinNorthernGhana................245

ParallelSession8-3Prioritysettingandeconomicevaluation....................246Primaryhealthcaredeliveryinpost-apartheidSouthAfrica:Exploringtheequity-enhancingcontributionsofthepublicsector..............................................................................246AreCommunityHealthWorkersthemissinglinkinimprovingcapacityofthehealthsystemspreventivearm?......................................................................................................................247Intra-urbaninequality,anewemergingchildhealthperilinAfrica:thecaseofSouthAfrica.............................................................................................................................................................247EconomicFluctuationsandChildMortality:HowWellChildren’sHealthNeedsareMetinNigeria......................................................................................................................................................248IdentifyingthechallengesinDeliveringtheEssentialHealthCarePackageinEswatini..........................................................................................................................................................................249ImplementingHealthFinancingReformsinNigeria:AcasestudyontheBasicHealthcareProvisionFund(BHCPF)...............................................................................................249

ParallelSession8-4HumanResourcesforHealth–innovativeapproaches.............................................................................................................................................250Themidwivesservicescheme:aqualitativecomparisonofcontextualdeterminantsoftheperformanceoftwostatesincentralNigeria.......................................................................250AnalysisofFactorsAffectingLeadershipTrainingTransferWithinaHealthSystemContext:LearningfromtheExperienceofKenya’sHealthcareLeaders...........................................................................................................................................................................251Theshort-termandlong-termcost-effectivenessofanaugmentedexercisereferralscheme:Awithin-trialanalysisandbeyond-trialmodelling................................................252FrontlineHealthWorkerPerformanceonMNCHCareatthePHCLevelsinNigeria.252Healthfacility-relateddeterminantsofchoiceforhealthcareprovider:lessonstowardsachievingthegoalsofuniversalhealthcoverageinUganda..............................253Patternsofincentivesforfrontlinehealthworkersatprimaryhealthcare(PHC)levelinNigeria:implicationsforhealthworkers’performance.....................................................254


Goingoperationalwithhealthsystemsgovernance:supervisionandincentivestohealthworkersforhigherqualityhealthcareinpublichealthfacilitiesinTanzania255

ParallelSession8-5Accesstohealthcareservices..........................................256AnalysisofthedeterminantsofhealthcaredemandchoiceinIvoryCoast...................256Factorsaffectingaccesstohealthcareandefforts/challengesinsecuringPHCinMalawi..........................................................................................................................................................................257QualityimprovementincommunityhealthinKenya:estimatingoutcomesforinvestmentdecisions..............................................................................................................................258TheEffectsofHealthCareAccessonChildNutritionalStatusinKenya..........................259PathwaystocareforpatientswithType2Diabetes,HIV/AIDSandotherchroniccomorbiditiesinSoweto:AHealthSystem’sPerspective......................................................260FactorsInhibitingEffectiveUtilisationofPrimaryHealthCareServicesinEredoLocalCouncilDevelopmentAreaofLagos,Nigeria...............................................................................260DeterminantsofaccesstoIvorianpublichospitals:Ananalysisbythecountingmodel...........................................................................................................................................................................261Obstaclesandfactorsfacilitatingaccesstosexualandreproductivehealth(SRH)servicesforyoungpeoplelivingwithdisabilities(YLD)inSenegal..................................262TowardsEffectiveImplementationofMaternalandChildHealthProgrammesinNigeria:LessonsforPolicyMakers..................................................................................................262

ParallelSession8-6Hospitalmanagementandfinancing.............................263Hospitalefficiencyinhealthcareuse:AcasestudyofRwanda............................................263Relationshipbetweenorganisationaljusticeandwork-relatedbehaviourofhealthprofessionals:evidencefrompublichospitalsinSouth-eastNigeria...............................264SecondaryhospitalefficiencyanalysisinEthiopia:Technicalandscaleefficiencyapplyingdataenvelopmentanalysismethod..............................................................................265ThedeterminantsofhealthcarequalityamongtheprivateandpublichospitalsinIbadanMetropolis,Nigeria..................................................................................................................266ProductiveefficiencyoftheIvorianhospitalsystem:ananalysisbytheDEA-Malmquist....................................................................................................................................................266AttributableCostandExtraLengthofStayofSurgicalSiteInfectionataGhanaianTeachingHospital....................................................................................................................................267DefinitionofUniversalHealthCoverageandPrimaryHealthCarePracticeatKayesHospital........................................................................................................................................................268

ParallelSession8-7NationalhealthInsurance.................................................268ExaminingtheExtentofBalancebillingintheGhanaianNationalHealthInsurance...........................................................................................................................................................................268AneconomicevaluationregardingthebenefitspackageofGhana’sNationalHealthInsuranceScheme....................................................................................................................................269JIS0GHAchecklistfordesigninganddevelopingcontributoryhealthinsuranceprogramsinNigeria................................................................................................................................270Delayedproviderclaimsreimbursementchallenges:adecadeaftertheimplementationoftheNationalHealthInsuranceSchemePolicyinGhana.Timetorethink...........................................................................................................................................................270

Posterpresentations...................................................................................................272

PosterPresentation1.................................................................................................273PosterPresentation2.................................................................................................281

PosterPresentation3.................................................................................................291


Agenda

Update: 09.03.2019

Bilingual

17:00 RegistrationParticipant seating

Housekeeping announcementsReception of officials

19:00

08:0008:30

08:30 10:3010:30 11:00

11:00 12:30

Room: ADLON BALLROOM 1Universal Health Coverage (UHC) -progress and challenges

Room: ADLON BALLROOM 2Private sector, PPP and contracting out 1

Room: ADLON 3Cost effectiveness: case studies

Room: PALM JUMERIAHAccess to HIV/AIDS services

Room: CHEZ GEORGEAccess to maternal health services

Room: EMIRATES PALACEEconomic evaluation of health programmes 1

Room: CIRAGAN PALACEData for management and policy making

Room: PEARLInstitutionalization of Financial Protection Monitoring in Africa (OS 1)

12:30 14:00

Room: ADLON BALLROOM 1Universal Health Coverage (UHC) - Monitoring and evaluation

Room: ADLON BALLROOM 2Equity in Health

Room: ADLON 3Community-based health insurance

Room: PALM JUMERIAHDrugs / Medicines

Room: CHEZ GEORGEEconomics of Immunization, malaria, TB and HIV/AIDS

Room: EMIRATES PALACEEconomic evaluation of health programmes 2

Room: CIRAGAN PALACEAid and International health financing

Room: PEARLToward Systematic Approaches for Addressing Ethics & Equity Considerations in Health Technology Assessment (OS 2)

14:0015:00

15:0016:30

Room: ADLON BALLROOM 1Strengthening Capacity for Teaching and Learning of Health Policy and Systems Research (HPSR) and Health Economics in Africa: Practical Issues for Educators and Learners (OS 3)

Room: ADLON BALLROOM 2Approaches for achieving Universal Health Care: Policy Perspectives from Africa and Asia (OS 4)

Room: ADLON 3How can health systems be shaped to sustainably address the maternal health needs of the most vulnerable and under-served populations? (OS 5)

Room: PALM JUMERIAHStrengthening health systems through the application of health financing progress matrices: country experience (OS 6)

Room: CHEZ GEORGEStrategic purchasing for universal health coverage: the role of aligned mixed provider payment systems (0S 7)

Room: EMIRATES PALACEIs a per capita payment system a viable strategic purchasing option for assuring universal access to Primary Health Care in Ghana: What have we learned over time and what is the way forward (OS 8)

Room: CIRAGAN PALACEThe influence of Cultural Practices in the spread of Diseases: the case of far North of Cameroon (OS 9)

Room: PEARLHow agent-based modelling can help healthcare policy and planning (OS 10)

16:3017:00

17:0018:30

19:00

Parallel sessions 3

BREAK / POSTER PRESENTATIONS

Plenary 2Main conference hall: ADLON BALLROOM 1-2Plenary session 2: Ghana’s road to UHC: improving enrolment onto the NHIS to achieve universal health coverage

Cocktail Dinner with World Bank

LUNCH

4- Tracking progress towards Universal Health Coverage: Methods and Applications using the World Bank’s ADePT software, Stata and the World Bank’s Health Equity and Financial Protection Indicator (HEFPI) database

Official opening ceremony

Official opening ceremony byHis Excellency Ajhaji Dr Mahamudu Bawumia, Vice President of the Republic of GhanaWELCOME COCKTAIL

Tuesday 12 March 2019Registration Housekeeping announcementsParticipant seating

Plenary 1Main conference hall: ADLON BALLROOM 1-2Technical Keynotes and Panel discussion - Securing PHC For All: the Foundation for Making Progress on UHC in Africa

BREAK / GROUP PHOTO / POSTER PRESENTATIONS

Parallel sessions 1

Parallel sessions 2

5 - The Power of Choice- Promoting Informed SRHR Choices among Young People to Advance the ICPD Agenda in Ghana

Pre-conference workshops1 - Scientific Writing Workshop

Monday 11 March 2019Pre-conference workshops

English only

2 - Skills building through peer learning – Implementing strategic purchasing to contribute to progress towards UHC in Africa

3 - Applied health economics in Africa: Using examples from immunisation

Sunday 10 March 2019

African Health Economics and Policy AssociationAssociation Africaine d'Economie et Politique de la Santé

Accra - Ghana 11th - 14th March 20195th AfHEA INTERNATIONAL CONFERENCE

The agenda at a glance

08:3010:00

10:00 10:30

10:3012:00

Room: ADLON BALLROOM 1Health financing assessments

Room: ADLON BALLROOM 2Maternal and child health care 1

Room: ADLON 3Result- and performance-based financing

Room: PALM JUMERIAHPurchasing of services

Room: CHEZ GEORGEUser fees' - removal and exemptions

Room: EMIRATES PALACEEvaluating PHC performance1

Room: CIRAGAN PALACEGovernance and accountability 1

Room: PEARLSound decision making – a development partnership for UHC (OS 11)

12:0013:30

Room: ADLON BALLROOM 1Health Financing and policy

Room: ADLON BALLROOM 2Maternal and child health care 2

Room: ADLON 3Health behaviours and perceptions

Room: PALM JUMERIAHHealth technology assessments

Room: CHEZ GEORGEMental health issues

Room: EMIRATES PALACEEvaluating PHC performance2

Room: CIRAGAN PALACE Governance and accountability 2

Room: PEARLTeaching Health Economics - a LMIC focus (OS 12)

13:3014:30

14:3016:00

Room: ADLON BALLROOM 1Public financial management towards better PHC and health sector outputs: Building and disseminating knowledge for accelerated reforms in Africa (OS 13)

Room: ADLON BALLROOM 2An Activist Agenda for Health Policy and Systems (HPS) Research and Practise in Africa (OS 14)

Room: ADLON 3Implementing Bold Reforms towards Financing UHC in a Decentralized Economy (OS 15)

Room: PALM JUMERIAHTranslating Evidence to Action: Participatory Approaches for Strengthening Maternal Health Interventions (OS 16)

Room: CHEZ GEORGEThe effect of human resources management on performance in hospitals in Sub-Saharan Arica (OS 17)

Room: EMIRATES PALACEPromoting access to quality and responsive mental health care and services in Ghana (OS 18)

Room: CIRAGAN PALACESecuring PHC for all in a voluntary health insurance: lessons from the NHIA-KOFIH collaboration in Ghana (OS 19)

Room: PEARLEconomics of Public Health: Implications for research practice in Africa (OS 20)

16:0016:30

16:3018:00

19:00 21:30 Gala Dinner

08:3010:00

10:00 10:30

10:3012:00

Room: ADLON BALLROOM 1Resource allocation, efficiency and management 1

Room: ADLON BALLROOM 2Non Communicable diseases

Room: ADLON 3New trends and debates in international health financing

Room: PALM JUMERIAHHuman Resources for Health: country experiences

Room: CHEZ GEORGEPreferences and willingness to pay

Room: EMIRATES PALACEHealth economics tools and approaches

Room: CIRAGAN PALACE Room: PEARLSexual reproductive health and rights: a smart investment towards achieving SDGs by 2030 (OS 21)

12:0013:30

Room: ADLON BALLROOM 1Resource allocation, efficiency and management 2

Room: ADLON BALLROOM 2Public health research issues

Room: ADLON 3Priority setting and economic evaluation

Room: PALM JUMERIAHHuman Resources for Health: innovative approaches

Room: CHEZ GEORGEAccess to health care services

Room: EMIRATES PALACEHospital management and financing

Room: CIRAGAN PALACENational health insurance

Room: PEARLPrivate sector, PPP and contracting out 2

13:3014:30

14:3016:0016:0016:15

16:1518:00

Social programme (by the Event Organizer)

Plenary 5Main conference hall: ADLON BALLROOM 1-2Plenarysession5:StrategicPurchasingforUHCinAfrica:Engagingstakeholderstoeffectivelyimplementstrategicpurchasingapproachesthatreachalllevelsofthehealthsystem


Parallel sessions 7

Parallel sessions 8

LUNCH

Plenary 6Mainconferencehall:ADLONBALLROOM1-2Plenary6:NationalhealthstrategiesforachievingPHCforall


Plenary 7Main conference hall: ADLON BALLROOM 1-2Plenarysession7: Panel discussion on key messages of the Conference

Closingceremony

Thursday 14 March 2019

Plenary 3Main conference hall: ADLON BALLROOM 1-2Plenary session 3: The cost-effectiveness and benefits of Sexual and Reproductive Health and Rights (SRH&R) packages within UHC related schemes


Parallel sessions 4

Parallel sessions 5

LUNCH

Parallel sessions 6


Plenary 4Main conference hall: ADLON BALLROOM 1-2Plenary session 4 - Making health systems work for UHC in Africa: An Actions Frameworkinstitutional meetings

Wednesday 13 March 2019


20

Oralpresentations


ParallelSession1–Organizedsession

OS 01 – Institutionalization of Financial Protection Monitoring in Africa

GraceKabaniha,RegionalOfficeforWorldHealthOrganizationinAfrica

Anestimated800millionpeoplesufferduetopooraccesstoservicesandafurther11.4%ofAfricansor14millionpeopleimpoverishedduetocatastrophicexpenditureonhealth.TheserepresentthechallengethatcountriesintheregionmustsurmounttoachieveUHCby2030.

ForcountriestoeffectivelymakeprogressinUHC,thereisaneedforcountriestoeffectivelymonitortheir progress. While much progress has been made in institutionalizing monitoring for servicecoverageandavailabilityusinghealthmanagementinformationsystemsandtheSARA(forexample)respectively; there has been little progress in institutionalization of financial protection. Thus farmonitoringoffinancialprotectionhasbeenthepreserveofacademicsormultilateralorganizations.There isneed tobuildcapacityof localpolicymakers togenerateandutilizeevidenceon financialprotectionintheircountries.

WHORegionalofficeinAfricahasoverthepastthreeyearsworkedwithfourteencountriestobuildinstitutionalcapacityandnationalteamsformonitoringfinancialprotectionforUHC.Sevencountriesweretrainedandhaveusedrecentdatatoestimateup-to-datestatusonfinancialprotectionintheircountries.

The purpose of this session is to share the experience of institutionalizing financial protectionmonitoringandsharerecentestimatesforsevencountries.

SessionFlow:

Openingofthesession:Dr:GraceKabaniha

Presentations:

a) Regional synthesis on status of Financial protection and drivers of catastrophicexpenditureinAfrica:whatarethepolicyimplications?(10mins)

b) StatusofFinancialProtectioninBurkinaFaso(10mins)c) StatusofFinancialProtectioninCoteD’Ivoire(10mins)d) CaseStudy4:StatusofFinancialProtectioninDemocraticRepublicofCongo(10mins)e) CaseStudy5:StatusofFinancialProtectioninMauritania(10mins)f) Casestudy6:StatusofFinancialProtectionandequityinfinancinginMauritius(10mins)

CountryPanelSession:(15mins)

Experienceofinstitutionalizationatthecountrylevel(enablersandchallenges)

QuestionandAnswerSession(15mins)


22

Analysis of financial risk protection in health. Case of the Democratic Republic of Congo.

Authors: Prof Gérard ELOKO EYA MATANGELO1, Eddy MONGANI MPONTONGWE,2 MINGIEDI MATONDOBOAZ,3AlainIYETI,4JeanPierreLOKONGANZEYABE,5JustineHSU,6AmédéeProsperDJIGUIMDE71&2. DRC Ministry of Public Health/National Health Accounts Programme; 3. National Institute ofStatistics/DRC;4.DirectorateforStudiesandPlanningintheMPH/DRC;5,6&7WorldHealthOrganization

BackgroundTheDemocraticRepublicofCongo(DRC)hasmadeprogressoverthepastfiveyearsinterms of economic growth andmacroeconomic stability. The country has experienced robust andsustainableeconomicgrowthatanaverageannualrateof7%since2009(PER/WorldBank2014;IMF2014).In2013,theDRCwasoneofthecountriesthatrecordedthestrongesteconomicgrowthintheregion at 8.5% in real terms, relative to a regional (i.e. Africa) average of 5.2%. This performancenotwithstanding,itsannualGDPpercapitaisstilloneofthelowestinSub-SaharanAfrica,accordingtotheCentralBankofCongo(US$426.1percapitain2016,incurrentdollars).Theinformalsectoraccountsforhalfofalleconomicactivitynationwide.

In2015,householdsfinancedhealthservicesandhealthcaretothetuneofUS$603767736outofthetotalUS$1505130858, representing40.1%ofannualcurrenthealthspending.Out-of-pocketpaymentsaccountedfor93.3%whilefundingthroughprepaymentmechanismswasamere6.69%.Consequently,theDRCGovernmenthascommittedtoactionforachievinguniversalhealthcoverageby2030

Methods It isadescriptivecrosscuttingstudythatanalysesthecatastrophichealthexpenditureofhouseholds based on data from the 1-2-3 surveys (Household Consumption Phase) conducted in2005 and 2012 by theNational Institute of statistics. Two approacheswere adopted, namely: thebudget-shareapproachfocusedonthedefinitionofcatastrophichealthexpenditureaccordingtothesustainabledevelopmentgoals(SDG3.8.2)andbasedontwothresholds-10%and25%ofthetotalhousehold expenditure or income; and the capacity-to-pay approach favoured by WHO whichconsidersahousehold’sexpensestobecatastrophicwhenitstotalhealthspendingisequivalenttoor above 40% of its capacity to pay. Logistic regression analysis was used to examine the keydeterminantsofhouseholdhealthspending.Theoddsratio(chanceorrisk)areinterpretedonlyforvariablesatp-value<0.05.

Results At the threshold of 10%, the proportion of households whose health expenditurerepresentedasignificantpercentageoftheirtotalspendingrosefrom3.9%in2005to4.8%in2012,representinga0.9-point increase.However, thispercentage(catastrophicspending)washigher forurbanhouseholds in 2005 and for rural households in 2012. Furthermore, a greater proportionofhouseholdsinthepoorestquintileengageincatastrophichealthspendingthanhouseholdsinotherquintiles.

Thestudyfoundthatruralhouseholdsare0.9timesmorelikelytoexperiencecatastrophicspendingthanurbanhouseholds.Householdsheadedbypersonswithahigher levelofeducationandricherhouseholdsarelesslikelytoengageincatastrophicspendingthanthoseheadedbytheuneducatedandpoorerones.Lastly,householdswithmembersaged60andaboveare0.45timesmorelikelytoengageincatastrophichealthspending.

Conclusion The study provided evidence of increasing incidence of catastrophic spending andimpoverishmentaswell as thedriversof financialhardship.Thisevidencewillbeuseful inguidingpolicyactionforthereformsforUHCintheDemocraticRepublicoftheCongo.

Keywords Health financing, out-of-pocket payments, catastrophic expenditure, impoverishment,odd-ratio


23

Analysis of health-related financial risk protection of household in Côte d’Ivoire from 2008 to 2015.

GbayoroKouaméChristelle1,ChristopheAguia1,LigbetMagloire2,LéonceNessenou2,TaniaBissouma-Ledjou31:MinistryofHealthandPublicHygiene-Côted’Ivoire,2:NationalInstituteofStatistics–Côted’Ivoire,3:WorldHealthOrganization

Background: Côte d’Ivoire has experienced remarkable economic growth from 517704 CFAF($1035.41) in 2008 to 838104.7 CFAF (1676.21)1in 2015.The poverty rate, which dropped from48.9%(2008)to46.3%(2015)2,remainshigh.Asof2012estimated7.8%ofthepopulationbenefitsfromhaving a health insurancemechanism3.Nevertheless, householdout-of-pocket payments arethe first source of health financing, accounting for 66.3% and 32.55% of total health expenditure(THE)in2008and2015respectively..Since2012,theproportionofthegovernmentbudgetallocatedforthehealthsectorhasremainedsteadyatanaverageof5.58%annually,whichisstillbelowthe15%Abujatarget.

Thisstudysoughttoanalyzethehealth-relatedfinancialriskprotectionofhouseholdsbydescribingtrendsinkeyhealth-relatedfinancialprotectionindicatorsandreviewingtheirequitabledistributionbasedonsocioeconomiccharacteristics

Methods Thisstudy isacross-sectional,analyticalanddescriptiveusingdata fromtwoHouseholdStandardofLivingSurveys(ENV)for2008and2015collectedfromrepresentativesamplesof12600and12899households,respectively.Samplesareconstitutedfromatwo-stagedclusteredpollingtoestimateincidenceofcatastrophichealthexpenditureandpovertyusingtwostandardmethods:theWHO methodology (capcacity to pay) and Sustainable Development Goals (SDG)methodology..FollowingtheWHOapproach,ahouseholdincursCHEiftheyuseatleast40%oftheircapacitytopaytocovertheout-of-pockethealthspending.FollowingtheSDGmethodology,theCHEis defined by the proportion of the population which incurs substantial household healthexpenditure, relative to the total expenditure or household income between 10 % and 25 %threshold.

To assess impoverishing expenditure caused by out-of-pocket spending, reference ismade of theratio of poverty incidence at the poverty line. The international poverty line of 3.10 USD(reference)was taken into consideration because the assessed poverty thresholdwas close to theone defined at country level,which is $1.32 (661 CFAF) in 2008 (reference) and $1.48 (737 CFAF)(reference)in2015.

Results At 10% threshold, it is observed that 12.4% of households experienced CHE in 2015comparedto17.4%in2008.At25%threshold,4%ofhouseholdsin2008comparedto3.8%in2015experiencedCHE.ThisreducuctioninincidenceofCHEisincorrelationwiththereporteddropinout-of-pockethealthspending.Theincidencewashigeherforricherquintiles.

The incidence of poverty reportedly reduced from 54.9% in 2008 to 53.6% in 2015. However, intermsofabsolutenumbers,roughly11millionpeoplein2018wereimpoverishedcomparedtoabout12million people in 2015 (an increase of 1million). The impact of out-of-pocket spending due toserviceutilizationhas resulted in theproportionofhouseholds livingbelowthis threshold tobeat58.1% and 56.1% in 2008 and 2015. Households with elderly people, located in rural areas, lesseducatedwereconsistentlymorepronetocatastrophicspendinginbothyears.

Conclusion The study provides someevidence of improving financial protection due to efforts todecrease out of pocket spending. Nevertheless the rising incidence of poverty is alarming. The

1 National Development Plan 2016 - 2020 2 Household Living Standards Survey 2015 3 Monitoring Progress Towards UHC in Côte d’Ivoire: Baseline Situational Analysis – WHO. Côte d’Ivoire, 2015


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evidencegeneratedinthisstudycanbeusedtoguidepolicydesignforhealthfinancingforUHCandfortargetingfinancialsubsidiesforthoseatgreatestriskoffinancialhardship.

Keywords Health financing, out-of-pocket payments, catastrophic expenditure, impoverishment,financialhardship

Trend of catastrophic health expenditure and their impact on the impoverishment of Mauritanian households between 2008 and 2014

MOHAMEDMAHMOUDOULDKHATRY,ALIOUNEGUEYE,KELLYAMINATASAKHO

BackgroundMauritania has expressed its commitment to achieving universal health coverage andtheSustainableDevelopmentGoals.Despite thestidesmade in improving thehealthstatusof thecountry, there is still room for improvement, as the gross mortality rate is still high at 10.9‰,comparedtothebirthrateof32.3‰,andlowlifeexpectancyof60.3years.Thehealthstatusofacountryiskeytomonitoringprogresstowardsuniversalhealthcoverage(UHC)andtheSustainableDevelopmentGoals (SDGs),and improving financialprotection. Thisstudyevaluates thestatusoffinancialprotectioninMauritania.

Methods The data used are from Permanent Surveys on Household Living Conditions (EPCV)conducted in2008and2014toestimate incidenceofcatastrophichealthexpenditureandpovertyusing two standard methods: the WHO methodology (capcacity to pay) and SustainableDevelopment Goals (SDG) methodology..Following theWHO approach, a household incurs CHE iftheyuseatleast40%oftheircapacitytopaytocovertheout-of-pockethealthspending.Followingthe SDG methodology, the CHE is defined by the proportion of the population which incurssubstantial household health expenditure, relative to the total expenditure or household incomebetween10%and25%threshold.

Results At 10% threshold, it is observed that 12.4% of households experienced CHE in 2015compared to According to the SDG approach, in 2008 and 2014, 10.8% and 11.2% of householdsrespectively, incurred catastrophic expenses at a threshold of 10%. At the 25% threshold,catastrophicexpenditure increased, irrespectiveof theareaof residence,withhigher incidences inrural areas, from1.1% in 2008 to 5.7% in 2014, and from1.4% in 2008 to 3.8% in 2014 in urbanareas.

AccordingtotheWHOapproach,4.9%ofMauritanianhouseholdsincurredcatastrophicexpenditurein2014,comparedto3.1%in2008.Catastrophicexpenditureincidence,from2008to2014followsthesametrendas theresultsobtainedwith theSDGapproach.Generally, thestudy findingsshowthatirrespectiveofthepovertyline,catastrophicexpenditureincreasedtheincidenceanddepthofpoverty.

Conclusion Attheendofthisstudy,weareoftheviewthattwomainrecommendationsmustbeimplemented without delay, in order to reduce the proportion of households facing catastrophicexpenditure.Intheshortterm,itisaquestionofputtinginplaceapolicyforcontrollingthecostsofpharmaceutical products. In themedium term, theaim is to introducehealth insurance coveragemeasuresforthepoor(16%ofthepopulation)andtheinformalsector.

Keywords Health financing, out-of-pocket payments, catastrophic expenditure, impoverishment,financialhardship


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Dynamics of catastrophic and impoverishment expenditures in Burkina Faso: an analysis of determinants.

GUENEHervéJean-Louis,DOAMBAOdilon,NASSASimon,ZAMPALIGREFatimata,COULIBALYSeydouO.

BackgroundThegovernmentofBurkinaFasohasembarkedonaprocessleadingtouniversalhealthcoverage with the enactment of Law N° 060-2015/CNT on a universal health insurance scheme(RAMU) in 2015. Based on the defined timing, the year 2018 should be devoted to theoperationalizationofthiskeyprogrammeforthebeneficiariesandstakeholdersofhealth.Sincetheestablishmentofahealthinsuranceisahighlycomplexprocess,itrequirestotalcontroloveralltheissuesbeforeimplementation.Itisworthnotingthathouseholds,themainbeneficiaries,wouldnotbenecessarilyaffected in thesamemanner.While somearealreadycovered,othersare incurringcatastrophicorimpoverishmentexpenditures.

The aim of this study is to estimate the extent of catastrophic and impoverishment expendituresamong the population and identify factors accounting for these expenditures over the 2009-2014period.

Methods Thestudyusesthedatafromthetwomostrecentsurveysonhouseholdlivingconditions(2009 and 2014). The descriptive statistics calculated for the relevant variables such as regions,residential settingandthequintileofhouseholdwealth,allowedforanassessmentofhouseholds.Ananalysisofdeterminantsof catastrophichealthexpenditureswas carriedout througha logisticregressiononthedatawithendogenousvariablessuchasthelikelihoodforthehouseholdtofinanceacatastrophicor impoverishmentexpenseand,asexogenousvariables, thegenderof theheadofhousehold,householdsize,structurebyageofthehousehold,etc.

Results Theproportionofhouseholdsthatincurcatastrophicexpendituresfellfrom1.3%in2009to0.8%in2014,andthatofhouseholdsincurringimpoverishmentexpenditurefellfrom1.9%to1.3%overthesameperiod.Factorssuchasthefactthatahouseholdissituatedinaruralareaorthatoneofitsmembershasbeenhospitalized,orthattherearepersonsagedover60yearsorunder5yeararethemainfactorsthataccountfortheoccurrenceofcatastrophicexpenditure.

Conclusion The study provided a categorization of households based on their level of healthexpenditures.Itshowsthat1.3%ofhouseholds,representing206217personsbecamepoorbecauseofout-of-pocketpayments.Thestudyconcludesthat interventionsofthehealth insuranceschememust give greater focus to hospitalizations, the elderly (60 years and over) and children (under 5year-olds),whorepresent26%ofthetotalpopulation.

Keywords Health financing, out-of-pocket payments, catastrophic expenditure, impoverishment,odd-ratio

Impact of Out of Pocket Payments on Financial Protection Indicators in a setting with no user fees: The case of Mauritius

YusufThorabally4†1,AjoyNundoochan†2!,SooneerazMonohur†3andJustineHsu4

Objectives: Since 1968 Mauritius provides free health care in all state-owned health facilities.Nevertheless since 2007 Private Health Expenditure (PvtHE) has surpassed General GovernmentHealthExpenditureasashareoftotalhealthexpenditure.PvtHEispredominatelycomposedofOut

† Equalcontributors!Correspondence:[email protected]


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of Pocket (OOP) with only 3.4% related to premiums for private insurance. OOP is known to beregressiveandto impactnegativelyahousehold’s livingstandards. ThispaperaimstounderstandtrendsinOOPanditsimpactonthepopulationofMauritiusthroughananalysisofkeyindicatorsoffinancial protection (i.e. Catastrophic Health Expenditure (CHE) and impoverishment due to OOPhealthexpenditure)andtoidentifythemaindriversofCHEs.

Methods: The Household Budget Surveys (HBS) of 2001/2002, 2006/2007 and 2012 were theprimary source data. Stata v11.2was extensively used for data analysis. CHE and impoverishmentwere used to assess financial hardships resulting from OOP payments. Incidence of CHE wasestimated using two standard approaches namely the capacity to pay and the budget share.ImpoverishmentduetoOOPwasmeasuredbychanges in the incidenceofpovertyandseverityofpovertyusingtheUS$3.1internationalpovertyline.ToidentifydeterminantsofCHE,weconductedalogisticregressionanalysis.

Findings:HouseholdCHEincreasedacrossallthethreethresholds(10%,25%and40%)from2001to2012. Over this period, incidence of CHE was more significant in urban area compared to 0.58percentagepointinruralarea.ThehighestlevelsofCHEswereexperiencedbyheadsofhouseholdswhoare retired (3.9%),widowed (2.8%)andhomemakers (2.5%).TheshareofhouseholdspushedbelowthepovertylineduetoOOPdroppedfrom0.0848%in2001/02to0.0445%in2006/07beforerisingto0.054%in2012.In2012,onlyhouseholdsclassifiedunderQuintile1(0.244%)andQuintile2(0.025%)weredriftedunderthepovertylineduetoOOPonhealth.

Conclusion:DespiteCHEhasbeenontheriseacrossmostincomegroupsoverthethreeconsecutiveHBSperiodtheimpactonthelevelofimpoverishmentandpovertygaphasnotbeensignificant.

Keywords:Catastrophichealthexpenditure,Impoverishment,Out-of-pocketpayments


ParallelSession1-Oralpresentations

Parallel session 1: Universal Health Coverage (UHC) – progress and challenges

Determining levels of satisfaction with roles of HMOs among beneficiaries of social health insurance scheme in Enugu, Southeast Nigeria

EricObikeze1,2ObinnaOnwujekwe1,2HesbornWao31. Dept of Health Admin.&Mgt., College ofMedicine, University of Nigeria, Enugu Campus; 2. HealthPolicy Research Group, College of Medicine, University of Nigeria, Enugu Campus; 3. African HealthPopulationandResearchCentre,Nairobi,KenyaBackground: Much as health insurance is being developed by countries at different levels,evidenceshowsthatgovernmentsoflowandmiddleincomecountriescanhardlymakeprogresswithout involving the private sector. This is amajor reasonwhy various forms of health carefinancingandenforcementmechanismsthatareprivatesectororientedarebeingputinplace.ToaidthatrequiresconsiderationofkeyissuesinUHC-heightofcoverage,depthofcoverageandbreadthofcoverage.InNigeria,HealthMaintenanceOrganizations(HMOs)arepositionedtorespondtotheUHCconsiderations.HoweverthereappearstobesomemissinglinksintherolesofHMOs.Currently, satisfaction that is required fromHMOsbybeneficiaries in the social andvoluntaryprivatehealthinsuranceschemesisnotglaring.ThisstudythereforelooksatthelevelofsatisfactionwithrolesofHMOsamongstbeneficiariesofbeneficiariesofsocialandvoluntaryprivatehealthinsuranceschemes.

Aim: aim of the study is to determining levels of satisfaction with roles of HMOs amongbeneficiariesofsocialhealthinsuranceschemesinEnugu,SoutheastNigeria.

Objectives: The study objectives are to 1) determine the extent of HMOs involvement inimplementationofsocial2)determinelevelsofsatisfactiononHMOsbybeneficiariesofhealthinsurance.

Methods: The study was a cross sectional descriptive design using quantitative method. Thequantitative data was from purposively selected Federal government employees that areregisteredwiththeNationalHealthInsuranceScheme(NHIS).Levelofsatisfactionwasgotusingcategorical variables in Likert format. Multinomial logistic regression model was used todeterminelevelofsatisfactionamongrespondents.

Findings:Therespondentsknowtheextentof involvementofHMOsinSocialHealthInsurance(60%).ManyoftherespondentsinthesocialhealthinsuranceratedHMOs(31.30%).Thosewhoratedthemverylow,was25.60%,highwas23.0%;veryhighwas17.0%andhighestwas3.10%.Level of satisfaction was statistically significant at 95% CI with Chi2 221.51 and p-value 0.00.OverallmultinomiallogisticregressionshowedChi2,Prob>Chi2andpseudoR2valuesof268.85,0.000and0.16respectively.

Conclusion: The study showed that respondentswerenotgenerally satisfiedwith the rolesofHMOsinthesocialhealthinsuranceschemeinEnugu,SoutheastNigeria.


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The challenges of achieving universal financial risk protection in Enugu State, South East Nigeria

Chikezie Nwankwor1,2, Ifeyinwa Arize1, Enyi Etiaba1, Chijioke Okoli1, Christian Okolo1, Eric Obikeze1 andObinnaOnwujekwe1

Department of Health Administration and Management, Faculty of Health Sciences and Technology,CollegeofMedicine,UniversityofNigeriaNsukka,EnuguCampus.Background: Out-of-pocket health spending continues to impoverish families amidstdeterioratinghealth indices inNigeria. InEnugu, southeastNigeria, theworst affectedare therural dwellers and the poorest, thus creating both socioeconomic and geographic inequity inaccess and use of services. This scenario raises questions as to what political and economiccapitalarerequiredtoensurethetransitiontouniversalhealthcoverage(UHC).

Objective: Thestudy’smainobjectivewastodeterminepolitical,economicandotherfacilitatorsand/or constraints to achieving universal financial risk protection (UFRP) in Enugu state,southeastNigeria.

Methods:Studywasconductedintwopurposivelychosenurban(Enugu-North)andrural(EnuguEast) local government areas, utilizing a cross-sectional study design and qualitative approachusing in-depth interviews (IDIs). Purposely selected key informants were healthcareadministratorsspreadacrossalllevelsandtiersofgovernment(MinistryofHealth,StateHealthBoard, State Primary Health Development Agency, cottage hospitals, PHC, House of AssemblyCommitteeonHealthandaNationalHealth InsuranceScheme(NHIS)deskofficer ina tertiaryinstitution).12outof17keyinformantsreturneddatathatwasanalysedonenablers/constraintstoachievinguniversalfinancialriskprotectioninthestate.

Results: This report exhumes the challenges to achieving UHC in Enugu state.Major politicalconstraining factors included lackof commitmentand insincerityofpurpose fromgovernmentand political handlers, poor health prioritization in government agenda, distrust betweengovernmentand labourunions,political instability, lackof constitutionaland legal frameworksfor citizens’ enlistment in health insurance, non-clamour from the electorate for theentrenchmentoftheirbasicrights,top-downapproachtoadvocacyandstructuringofinsuranceprogrammes for states by the NHIS, and public corruption. Economic challenges adducedincluded thin fiscal space to expand healthcare programmes, and lack of demonstrableaccountabilitymechanisms in the design and structuring of insurance programmes for states.Other challenges proposed included poor education of the masses on ways to access NHISavailable routes to pre-payment programmes, and lack of human resources and manpowerdevelopmentforhealthsystems.

Discussion & Conclusions: State governments including Enugu is yet to commit to providingUFRP for its residents because of identified political and economic hurdles. These portend agreat obstacle to achieving UHC for inclusive and sustainable development in the state. Thisstudysuggeststheencouragementofconsciouspolicydialoguesamongstakeholders,especiallyamonggovernmentandcitizen’srepresentativestoentrenchUHCintheshortestpossibletime.

Moving towards universal health coverage: The need for a strengthened planning process

JulietNabyonga-Orem,WHO,HarareZimbabweAs countries embrace the ambitious universal health coverage (UHC) agenda whose majortenents include reaching everyone with the needed good quality services, strengthening theplanning process to work towards a common objective is paramount. Drawing from countryexperiences—Swaziland and Zanzibar, we reviewed strategic planning processes to assess theextenttowhichtheyimpactonrealisingalignmenttowardsacollectivehealthsectorobjective.


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Employing qualitative approaches, we reviewed strategic plans under implementation in thehealthsectorandusinganinterviewguideconsistingofopen-endedquestions,interviewedkeyinformantsat thenationalanddistrict level.Results showed that strategicplansare toomanywithmajorityofprogramstrategiesnotwellalignedtothehealthsectorstrategicplan,arenotcosted, and there overlaps in objectives among the several strategies addressing the sameprogram. Weaknesses in the development process, perceived poor quality of the strategies,limitedcapacity,highstaffturnover,andinadequatefundingweretheidentifiedchallengesthatabatetheutilityofthestrategicplans.MovingtowardsUHCstartswitharobustplanningprocessthat rallies all actors and all available resources around a common objective. The planningprocess should be strengthened through ensuring participatory processes, evidence informedprioritisation, MoH institutional capacity to lead the process, and consideration forimplementation feasibility. Flexibility to take into consideration emerging evidence and newdevelopmentsinglobalhealthneedsconsideration.

Health Insurance for Informal Sector Workers in Côte d'Ivoire: Lessons Learned from the Implementation of the MCMA

*DOUA Ruphin, **BAMBA Lassiné and ***BEYERA Isabelle: *UFHB, **Fondation AVSI-Côte d’Ivoire,***BEYERAIsabelle Backgroundandrationale:TheWorldHealthOrganization(WHO),initsreportonglobalhealth2010,highlightedtherightofalltoaccessqualityhealthcare.About70to90%ofworkersintheinformalsectorarestilloutofreachofexistinghealthcoverageschemesindevelopingcountries,particularlyinAfrica.InCôted'Ivoire,thissituationremainsthemainconcernforworkersinthecraftsector,characterizedbyahighlevelofinformalityandprecariousnessofactivities.Indeed,almostallcraftsmenandtheirhouseholdsdonotbenefitfromanyprotectionagainsttheriskofillnessandareexposedtotheheavyfinancialconsequencesofdirectpayments;whichincreasestheir vulnerability to poverty. Faced with this situation, the AVSI-Côte d'Ivoire Foundation, incollaborationwiththeNationalChamberofTradesofCôted'Ivoire(CNMCI),initiated,aspartofits Integrated Project to Support the Empowerment of Artisans of Ivory Coast (PIAAA-CI), aDiseaseCoverageMechanismforArtisans(MCMA).

Objective andMethodology: This study assesses the extent towhichMCMAhas achieved itsobjectives.ThisstudyaimstocapitalizeonthelessonslearnedforscalingupundertheCMU.Thestudy is based on a particularly qualitative, comprehensively oriented evaluation approachfocusedonsemi-structuredinterviewsandfocusgroups.

Resultsandrecommendations:Theresultsshowthat,whiletheMCMAisaresponsetohealthcareconcerns,therearesignsthatcouldhinderitssustainability.ThesesignsaretheresultofanumberoffactorsthatweakentheMCMA;andwhichaccountforthedifficultiesandconstraintsthatactorshave in termsof itsappropriation. Inaddition to thesesigns, there is collaborationbetween the various institutional players that needs to be further energized to respondeffectively to the difficulties and constraints faced by MCMA on the ground. We thereforerecommendastrongcommitmentand involvementofall the institutionalactorsandthemainbeneficiaries.ItisnecessaryforthesekeyactorstolearnfromitsimplementationforscalingupundertheUHC.ItisonthisconditionthatCôted'Ivoirewillbeabletotrulyadvancetowardstheuniversalityofhealthcoverage.

Revitalizing Primary Health Care to Achieve Universal Health Coverage in Mauritius

*LaurentMUSANGO,**DR.MaryamTIMOL,***PremduthBURHOO: *Port Louis WHO, **Ministry ofHealthandQualityofLife,***MauritiusInstituteofHealth


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In Mauritius, the strong primary health care system provides geographically accessiblehealthcarefreeatpointofusetoallcitizensandthisitisrespondingtoboththepopulationandindividual needs with a range of services that cover all the elements of care namely healthpromotion,diseaseprevention,curativeservices,andrehabilitation.However,itwasfoundthatprimaryHealthCareisnotplayingitsgatekeepingroleeffectively,reasonwhyanassessmentonstrengtheningprimaryhealthcareforbetteroutcomeswasinitiatedinMauritius.

Thecountryassessmentstartswithathoroughanalysisofthesituationofservicesdeliveryoverthepast15years.Challengesorpresentopportunitiesforimprovingservicesdeliverywerethencarried out. A participatory and flexible approach was used for this assessment; amultidisciplinary team was set up to carry out the assessment. A Working Group (WG) of 6members was constituted to review and to validate the report. The report identified keysopportunities that the country may continue to build on as well as challenges and possiblesolutions to address them through strengthening Primary Health Care to Achieve UniversalHealthCoverageinMauritius.

Theassessmentshowsthat,inmanycases,thegatekeeperroleofprimaryhealthcareprovidersis bypassed.Many patients attend the hospitals directly particularly outside opening hours ofPHCs.Evenduringworkinghourspatientsoftenattendsecondaryortertiarycareinstitutionsfornon-complicatedcasesaspriorreferral isnotarequirement.Patientshaveanover-relianceonhospitals and prefer to receive follow-up care at the hospitals with the specialists. Currently,there isnohealth informationsystem inplace in thePHCs toassist in their roleasahub.TheabsenceofauniquepatientidentifiernumberresultsinduplicationofcareatPHCsandinabilitytotrack/tracepatientsinthepublichealthsystemwasalsonoted.Continuityoftreatmentandrapport building with a particular health worker is difficult with the present service model.Moreover,choiceofhealthcareproviderisnotpossibleinthepresenthealthsystem.

Theassessment recommended furthering consolidating the roleofPrimaryHealthCareas thecentreofhealthcarebyreducingduplicationofservicesatPHCandhospital levels,strengthentheroleofPHCinimprovingcoordinationbetweenprimary,secondaryandtertiarycarelevels,having amore systematic screening andmanagement of chronic conditions in PHC aswell asscaleupprimaryhealthcareservicestorespondtotheageingpopulationandincreasingratesofmulti-morbidity. The road map for the implementation of the recommendations was alsoapprovedbytheMinistryofhealthandstakeholders.

Crunch Time: the transformational Universal Health Coverage agenda for Zambia

MpumaKamanga,Lusaka,MinistryofHealth There is a realisation worldwide that health expenditure can be catastrophic, exacerbateinequalities between poor and rich households, and drive people into poverty. As such, anumberofcountriesseektoprovideUniversalHealthCoverage(UHC)toallitscitizensinorderforeveryonetoaccessqualityhealthcarewithoutfinancialadversity.However,attainingUHCisdifficult. It has also been recognised that there is no universal formula for attainingUHC, andthateachcountrymustcarveitsown.ThispaperdescribesZambia’strajectorytoachievingUHCfrom the 1990s to date. The paper highlights some of the past institutional and financingreforms, achievementsmade; and gaps and challenges that the government is determined toaddress throughanexplicit transformational agenda that is currentlybeing implemented. ThisagendaisbeingpursuedwithrenewedvigourgiventhatZambia’seconomyandpopulationaregrowingrapidly,thetimetotransitionfromexternalsupportisfastapproaching,andthediseaseprofileischanging.


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Politicking with Health Care and Its Implication for The Attainment of Universal Health Coverage

Aloysius Odii,Obinna Onwujekwe, Ada Ogbozor, Tochukwu Orjiakor, Prince Agwu, Eleanor Hutchinson,DinaBabalanova,andMartinMckee Background:AhighpriorityhealthpolicygoalinNigeriaistheachievementofthehealth-relatedSustainableDevelopmentGoals (SDGs),especiallyUniversalHealthCoverage (UHC) thatwouldensure citizens access health services without experiencing financial difficulties by 2030. InNigeria,thePrimaryHealthcaresystemisrecognisedastheepi-centreoftheeffortstoachieveUHC.However,thenatureofpoliticsthatreportedlyexistsatthePHC,especiallywithinhealthcentresmayconstraintheachievementofUHC.However,there ispaucityofknowledgeoftheeffectsofpoliticsatthePHClevelontheachievementofUHC.

Objectives:ThestudyexaminedtheeffectsofhowplayingpoliticswiththehealthcentrecreatesstructuralandinstitutionalbarriersthatpreventsPHCsfromcontributingtotheachievementofhealthgoalssuchasUHC.

Methodology:The studywas carriedout ineightPHC facilities thatwerepurposively selectedfromfourlocalgovernmentsinEnuguState,southeastNigeria.Datawascollectedusingin-depthinterviews(IDIs)fromtwentyparticipantsthatincludedfrontlinehealthworkers,servicesusers,headofdepartmentofhealth,supervisorsforhealthandthechairmenofthecommunityhealthcommittees.Four(4)Focusgroupdiscussions(FGD)wereheldwithmaleandfemaleconsumers.

Findings:Itwasfoundthatpolitics(becausetheinterestofpowerfulmembersofthecommunityareconsidered)influencesthesitingofPHCfacilitiesandsomearesitedingeographiclocationsthat constrain optimal access to health services. Also, the recruitment of healthworkers is inmost cases not based on merit but on the principle of who-you-know and in such cases,incompetent hands could be employed leading to poor health care delivery.Moreover, somehealthworkerscanafford tobeabsent fromdutywithoutsanctionsbecausemost times, theyareprotectedbyinfluentialpersons.

Conclusions/Recommendations:PolitickingwithhealthcareleadstopoorrunningofPHCsanditmakesusersaccesshealthservices infarandcostlyplacestherebymakingthegoalofrealizingUHCdoubtful.ToachieveUHC,governmentsatall levels shoulddevelopmechanisms thatwilllead todecrease in the corruptiveanddisruptive influencesofpolitics at thePHC level. Thereshould be a deliberate emphasis on meritocracy in the recruitment and siting of PHCs. Inaddition, the government should develop reporting platforms that allows community healthcommitteesgoabovehealthworkersandtheirmanagersthatarecorruptanddisruptingthePHCsystem.Acknowledgement:ACEconsortium

Achieving universal health coverage in nigeria through health financing

Aniefiok Udo Department of Economics, University of Calabar; Iboro Nelson Department of Economics,UniversityofUyo;JeremiahOluDepartmentofEconomics,KogiStateUniversity

INTRODUCTIONUHCentailsthatcitizenshaveaccesstothehealthcareservicesneededwithout undue financial hardship. This consist of three interrelated components: thepopulation covered, the range of services made available; and the extent of financialprotection from the costs of health services. Health is a priority for the state and a socialobligationforallcitizensbutNigerianhealthcarefunding isgrossly inadequatewithbudgetaryprovision to health barely exceeding 3% of the country’s total budget. Also, there is lack of


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incentivesforhealthproviderstosetupfacilitiesinruralareas(inequityofaccess).Publichealthexpenditures in Nigeria account for only 20-30% of total health expenditures, while privateexpenditures accounts for the remaining 70-80%. Again, there is lack of provision for thepotentialexclusionofthoseunabletopayfromthenationalhealthinsurancescheme(NHIS)orsetting premiums for poorer people (inequity in finance). Nigeria is still ranks low among theWorld Health Organisation (WHO) member nations. The dominant private expenditure isthroughout-of-pocket,andthisaccountsformorethan90%ofprivatehealthexpenditures.Thisstudy seeks to examine the nexus between public health care financing and achievingUHC inNigeria.

METHOD The study utilizes multivariate logistic model as empirical technique in analyzingprimarydata collected throughpersonal interview from randomly selected sample sizeof 720households.20eachfromsixvillagesof thetwo localgovernmentareachosenfromthethreesenatorialdistrictsinAkwaIbomstate.

RESULT/CONCLUSIONTheresultshowsthat64.3percenthadonlyaccessedthehealthfacilitieslessthan4timeswithinthemonthforchildhoodrelatedtreatment,while35.7hadaccessedthehealth facilitymore than five timeswithin themonth. Also the findings reveals that the highlevelsofinfantmortalityratewasassociatedwiththehighincidenceofout-of-pocketpayment,and the wide disparity and inequality in income distribution. The study further observed aninequalityinthedistributionofhealthfacilities,moreinurbanwhilelessinruralareas.Thestudythereforerecommendedamongotherthingsthatincreaseinpublichealthspendingisrequiredtoreducetheburdenofcostofhealthservicesintheruralareas.

Parallel Session 1-2 Private sector, PPP and contracting out

Governing Public Private Partnerships to advance UHC objectives: Experiences from Government- Private Not-for-Profit contractual relationships in Uganda

Aloysius Ssennyonjo, Justine Namakula and Freddie Ssengooba , Makerere University School of PublicHealthUganda

Background:Government–PrivatenotforProfit(PNFP)relationsarevitaltoadvanceUniversalHealthcoverage(UHC)indevelopingcountriesbutfacemajorcapacitychallengessuchas“buyormake”decisionsandcapacityforrelationalgovernancesystemstosupportmutualobjectives.This study examines how Government-PNFP contractual relationships can be governed toadvanceUHCobjectives.

Methods: This study was part of Multi-country studies commissioned by Alliance for HealthPolicy and Systems Research /WHO. The Case study about Uganda Catholic Medical Bureau-Government relationship to support health sector development/investment plans over time.Methodsincluded;documentreview,secondarydataextractionand39keyinformantinterviewswithactorsat,district,facilityandnationallevel.ThestudyutilizedPrincipal-agencytheory,Newinstitutional economics and path dependence to explore evolutions and dynamics in thecontractualrelationshipsbetweengovernmentandPNFPovertime.

Key findings: The relationship between government and PNFPs was built on pro-poorcommitment of the PNFP sub-sector especially evidenced by PNFP presence in rural facilities.ThisledtoprivilegedpositionofPNFPsinhealthgovernancestructuresandprocessesprovidingopportunities for PNFPs to contribute directly to policy development and implementation


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processes.ThedilemmaofperformancespecificationandmonitoringandtheconflictbetweenPNFP autonomy and co-option byGovernment are key issues in principal-agency relationship.Mistrust over subsidies and costs were prevalent: Government officials questioned whygovernment should subsidize the PNFP sub-sector yet it continues to charge fees for theirservices, yet they receive government subsidies and substantial financial andmaterial supportfromcharitableorganizationsandexternalaidagencies.Thebasisfortheactualcostofservicesin PNFPwasnot transparently determined.Weak financialmanagement systemsamongPNFPfacilitieswereconsideredamajorchallengeinthepastbuthavenowimproved.ThePNFPsmadeinternal efforts to improve capacity including training the teams and streamline internalexpectationsofemployees.TheMinistrywasalsoperceivedtohaveweakcapacity tomeet itsobligationsinthepartnership.

Conclusions: Government of Public Private Partnerships (PPPs) has political economy issueswhichcanbecomplicatedbyinformationinadequacy.Trustandsuspicionsneedtobemanagedby closer engagement of parties involved in the partnership. Clarification of expectations ofpartnersashasbeenpracticedunderResults-basedfinancing(RBF)schemespilotedacrossthecountrycanenableimprovementoftheprincipal-agencyrelationship.

Trust me if you can! Realist insights on how mistrust undermines effective Public Private Engagement and strategies to address it in West-Africa

Jean-PaulDossou*,BrunoMarchal**,SosthèneAdisso**CentredeRechercheenReproductionHumaineetenDémographie,Cotonou**InstitutdeMédecineTropicale,Anvers

BarrierstoeffectivePublic-PrivateEngagementforhealthinWest-Africaincludeideologicalrifts,conflictinginterestsandlimitedgovernancecapabilities.Littleisknownonhowtheseelementsjointly cause engagement failures. We used the implementation of the fee exemption forcaesarean section policy introduced in Benin in 2009 to investigate how the engagement ofprivateprovidersisorganisedandregulated.WeadoptedaRealistEvaluationapproach(Pawson&Tilley,1997)andusedanembeddedcasestudydesign,usingqualitativeandquantitativedata.

Thefeeexemptionpolicyonlyconsiderspublicandnot-for-profitprivateactors,onthegroundsthatthenon-profitprivatesectorsharesthevalueofpublicorientedservicesandcanbetrustedto implement thepolicy.However,we found that,analysing the feesat44health facilities,14privatenot-for-profitfacilitieskeptchargingthepatientssubstantialadditionalfeesontopofthe€153 per caesarean section reimbursed by the government. Our analysis shows howimplementationof thispolicybyprivatenot-for-profit facilitiesdependsonhowtop-downandbottom-uptrustisfacilitated.

Inacontextwherethepublicadministrationisseenastoobureaucratic,slowandunreliableinits financial procedures, hospital managers perceive the fee exemption policy as a threat,especially if out-of pocket payment is their main funding source. In such cases, hospitalmanagerswhohavethedecisionspacetodosoaremorelikelytochargeextrafeesandpreventuserstoreceivethefullbenefitfromthefeeexemptionpolicy.

We found that trust between state and private-not-profit providers is more likely to befacilitatedby(1)removingtheriskforprivateactorsoflosingresources,forinstancebysettingupsimple,reliableandtransparentadministrativeprocedures;(2)takingintoaccounttheactualcostforfacilitiesofimplementingthepolicy;(3)compensatingshort-termfinanciallossincaseofdelayedreimbursements; (4)usingevidencetomakeexplicit thechallengesofeachsub-sector(publicorpublicnotforprofit)inimplementingthepolicytofacilitatearicherandmoreinclusive


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policy debate; (5) making each sub-sector accountable for its commitments toward thesuccessfulimplementationofthepolicy.

Inconclusion,wefoundadynamic interplaybetweenfinancial interests,decisionspace,powerandtrustattheinterfacebetweenthepublicandprivate-not-profithealthsectorinBenin.SinceUHCrequiresamobilisationofallactors,promotingtrustbetweenpublicandprivateactorswillbeessentialtoachieveuniversalhealthcoverageinWest-Africa.

The Nigerian PBF Approach to Contracting Using State Actors

HyeladziraDavidGarnvwa,ProjectImplementationUnit,NigeriaStateHealthInvestmentProject(NSHIP),NationalPrimaryHealthCareDevelopmentAgency(NPHCDA)

BackgroundIn2011,theFederalGovernmentofNigeria(FGN)throughacreditfromtheWorldBanklaunchedaResults-basedfinancing(RBF)programinhealthundertheNigeriaStateHealthInvestment Project (NSHIP) piloted in three States of the Federation. The RBF approach wasadoptedbasedonglobalbestpracticesandexperiencesfromothersub-SaharancountriessuchasRwandaandBurundi,asanoutput-basedsystemofhealthfinancing.

IntroducingRBFapproachesintoacountryisnotalwayseasyandneedstofollowbasicprincipleswhicharerelevantfordesigningcountrymodels,however,eachcountryhastodesignoradaptitsRBFmodelbasedonitsrealities.

In Nigeria, consultations between FGN and the World Bank was key to identifying andconsidering country level nuances required for the introduction of RBF. This includes aligningwith the Africa Strategy (2011) – Africa’s Future and the World Bank’s Support to it whichfocuses on the foundation of strengthening governance and building public sector capacitythroughinstitutionalstrengtheningandenhancingincentivesinthecivilservice.

ObjectivesThisresearchaimstoassessthedegreetowhichthedesignofNSHIPadherestotheconceptualdesignandframeworkofRBFprogramsbasedonitselevenbestpractices.

MethodologyTomeettheobjectiveofthisresearch,wemeasureitsfidelityagainstthedistinctroles that various actors play in an ideal RBF setting. Literature review of RBF in developingcountries,PBFtoolkitandguidelinesandtheNSHIPprojectdocumentswasdonetocollectdata.ThecaseisdefinedastheNigerianNSHIPRBFmodelfromlate2011to2017andanalysisismadebasedonthemodifiedimplementationfidelityframeworkofCarrolletal.(2007).

Key findings Thestudyfoundthemajorityoftheinterventioncomponentswereimplementedwith fidelity (80%, 4/5), whiles 20% (1/5) underwent modifications due to contextualcircumstances.Empiricaldatashowedthattheinstitutionalarrangementbasedonseparationoffunctionswereimplementedwithslightadaptationsmadeoncountrylevelnuances.

ConclusionExperiencefromtheNSHIPmodelsuggeststhatintegratingRBFapproachesintothehealthsystemfirstrequiresadesignmechanismthatincludesadequatespacefordialogueanddebate to ensure understanding and ownership among key stakeholders. Secondly, alignmentwithandadaptationto,thespecific,localinstitutionalcontextiscritical.

Sofar,theNigerianRBFapproachtocontractingisuniqueasitshowsthatthecapacityofStateactorscanbebuilttotakeonnewrolesinRBFdesignandimplementation.

Faith based health providers are less affordable to access for PLHIV, a comparative study from North Tanzania

CarlMhina,CenteMedicalChrétienduKilimandjaro


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Background: The third sustainable development goal emphasizes on improving individual’saccess to needed health services and protecting them from financial catastrophes andimpoverishing health care costs.While access toHIV care is a complex concepts that interactwithdifferentsocio-economicfactors,littleisknownonhowthesemaydifferbetweendifferenthealthproviders.Faithbasedhealthproviders(FBHP)representanimportantsourceofcareforall socio-economic groups especially for those in the rural areas due to their affordability,availability and acceptability. This study investigated the relationship between health facilityownershipandaccesstoHIVcareinNorthernTanzania.

Methods:We conducted a patient-cost study in two purposively selected HIV/AIDS care andtreatment centers, a faith-based and a state-owned. A total of 618 clinic exit interviewswereconducted;336fromthefaith-basedhealthfacilityandatotalof282fromthepublichospitals.Threedimensionsofaccess (affordability,acceptabilityandacceptability)wereevaluatedusingpatientexitinterviews.WethencomparedthethreeaccessdimensionsaccordingtothehealthproviderusingthePearsonx2,FischerexactandMann-WhitneyUtestswereappropriate.

Results: Only 22% of the participants had any form of health insurance cover with a largerproportion intheFBHP(109[32.4%]vs27[9.6%],P=0.000).ThetotaldirectcostspaidtothehospitalpervisitwashighintheFBHP($1.6[SD1.4]vs$0.1[SD0.8],P=0.000)withaslightlylargerproportionofparticipantsfromtheFBHPsufferingcatastrophichealthexpendituresfromdirectcostspaidoutofpocketcomparedtothosefromPHata10%threshold(115[34.2]vs86[31%]P=0.324).60% (97/336)of theparticipantswithchronic illness in theFBHPreceivedcarefromthesamecliniccomparedto37%(43/282)fromthepublichospital.Mostoftheparticipants546[82.4%]hadneverexperiencednegativejudgementfromthehealthworkersandtherewasnodifferencebetweentheproviders(282[83.9%]vs227[80.5%]P=0.136).Conclusion:FBHPSaregenerallylessaffordablecomparedtopublicproviderswithhighcostsofservicesandaccess,although this ismorecomplexwhenassessedclosely.Services forchronicdiseasesother thanHIV/AIDSwere readily available in the FBHP.Contrary topreviousnotions,both providers have high level of acceptability. Interventions and policies addressing accessbarriersneed to concentrateonhealthprovider’smodelsof access thatprotectpatients fromhighout-of-pocketsandcatastrophichealthexpenditures.

Mobilizing resources from the private sector for targeted health investments using evidence from costing assessments

SylvesterAkande,PalladiumInternational_Nigeria,AbujaBettaEdu,CrossRiverStatePrimaryHealthCareDevelopmentAgencyBackground:GovernmentsinNigeriaarestrivingtoinjectcapitalintothehealthcaresectorbutthechallengesof lowrevenuegeneration,taxreceipts,andinefficiencies inhealthexpenditurecomplicate these efforts. It is for this reason that health policymakers now look to innovativepublic-privatepartnershipsasawayofexpandingthefiscalspaceforHealth.In2017,theFederalGovernmentflaggedoffaschemetorevitalize10,000primaryhealthcarecenters(PHCs)acrossNigeria as part of advancing progress towards Universal Health Coverage (UHC). ThisrevitalizationinitiativeseeksafullyfunctionalPHCineveryadministrativewardofthecountry.The Government of Cross River State (CRS) has adopted the initiative and has committed torevitalizingatotalof196PHCsacross196politicalwards.

Methodology:Withtechnicalsupport fromUSAID, theCRSGovernmentconductedanRMNCHServiceAvailabilityandReadinessAssessment(SARA)toidentifycriticalserviceinputgapsat750healthfacilities.Datawereaggregatedandpresentedbyfacilitytypealongthe linesofHumanresources for Health, Infrastructure, Commodities and Supplies, and Equipment. Furthermore,


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the infrastructuregapswerecostedusingtheBillsofQuantity (BoQ)methodologytoascertainthe financial needs required to close identified gaps through targeted investment. Indicesassessed include power supply, water supply, roofing/building/floor/window/door conditions,toiletfacilities,andwastemanagementfacilities.

KeyFindings:Infrastructureinthestate’spublichealthfacilitiesisgenerallypoor.Approximately,halfofallfacilitiesvisitedhadaleakingroof,noaccesstowater,electricityorafunctionaltoilet.In 2018, the CRS PrimaryHealth CareDevelopment Agency leadership launched the “Adopt aHealthFacility”initiativeusingevidencefromtheBoQassessmenttoengagetheprivatesectorwithaviewtohavingthemcontributetotherenovationofthe196mainPHCsperward.Todate,40 facilities have had their infrastructures upgraded and an additional 7 PHCs have receivedbasicequipmentfromwell-meaningindividuals.ThisisseparatefromthePHCsthatshallbefullyrevitalizedusingpublicfundsthroughevidence-basedpriorityneedsbudgeting.Main Conclusion: Inmany LMICs,mobilizing resources fromGovernment alone to bridge thehugecritical service inputgaps forqualityRMNCAH+NMservices isabig challenge.Financialand non-financial resources from the private sector can significantly contribute to theGovernment’s efforts by complementing, strengthening, and extending existing resources.However, to engage the private sector effectively; generating evidence of need, establishingrobustaccountabilitymechanismsandefficiencyimprovementswillbecriticalintranslatingthepotentialofmobilizingadditionalresourcesfromthissectorintoreality.

Parallel Session 1-3 (Cost effectiveness: case studies)

Costs and sustainability of a novel Community Health Workers programme in improving Mother and Child Health in Nigeria

ObinnaOnwujekwe;HealthPolicyResearchGroup,UniversitéduNigériaNsukkaTimEnsor,BenjaminUzochukwu,UcheEzenwaka,AdaobiOgbozor,ChinyereOkeke,EnyiEtiaba,reinhardHuss,BasseyEbensoandTolibMirzoev

Background: A recent health intervention that was undertaken in Nigeria was the SubsidyReinvestment and Empowerment Program/ Maternal and Child Health (SURE-P/MCH)programme,whichhadbothsupplyanddemandcomponents.Thefundingfor theprogrammeendedin2015,butthereistheneedtoprovideevidenceonitsperformance.Hence,thisstudyprovides evidence on the costs and cost-effectiveness of the intervention, which has directbearingon its sustainability and scalingupof communityhealthworkerprogrammes forMCHinterventions.

Methods: The studywas undertaken inAnambra state, southeastNigeria. Cost andoutcomesdatawere collected from three clusters; (1)With the SURE-PMCH intervention; (2)With theSURE-PMCHintervention+CCTand;(3)WithouttheSURE-PMCHintervention.Costswerefortheyear2014.Informationwascollectedfromrelevantkeyinformantsandfromtherecordsinhealth facilities, local government councils, and the state ministry of health. The costs werecategorizedinto:personnel,infrastructural(capital),drugsandconsumables,overheadandCCTcosts.DataontheoutcomesoftheinterventionarebeingcollectedusingacommunitysurveyinthethreeclustersandtheresultswillbeavailableinJuly2018.

Key Findings: The highest total annual cost was incurred in the SURE-P +CCT facilities(93,643,613 Naira: US$307,028) and the least cost was incurred by the control facilities


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(52,717,114NairaUS$172,843). The clusterwith just the SURE-PMCH incurred a total annualcostof79,343,727Naira(US$260,143).ThehighestcontributorstocostsintheSURE-Pfacilitieswere frompersonnel costs and drugs and consumable. The cost on infrastructurewas almostuniformacrossthethreesites.TheeffectivenessoftheinterventionsincreasedmovingfromtheSURE-PCCTcluster to theSURE-Pnon-CCTcluster to thecontrolcluster, forANCanddelivery,butnotforPNC.

MainConclusion:ThereisawidevariationintheannualcostonMCHservicesacrossthethreeclusters. The findingofoverall positive incremental cost analyses from theCCT cluster to thenon-CCT SURE-P cluster to the control clusterwere expectedly because of the higher level ofactivitiesintheSURE-PCCTandnon-CCTclusterscomparedtothecontrolcluster.Thecostsandconsequencesshowthatthereareefficiencygapsbutalthoughtheprogrammecanbeusedtoimprove access to MCH services, the relatively most costly CCT cluster calls to question thesustainabilityoftheCCTcomponent,especiallyifrunasroutineprogramme.

Examining the affordability of hypertension care in Kenyan hospitals: a cost analysis from the patient’s perspective

Robinson Oyando1, Edwine Barasa1,Martin Njoroge1, Peter Nguhiu1, Fredrick Kirui3, JaneMbui3, AntipaSigilai1, Esther Muthumbi1, Sailoki Kapesa1, Joseph Mwatha4, Vincent Okungu1, Lawrence Muthami5,ZipporahBukania5, JudyMwai6,MargaretWambua7,AndrewObala8,KennethMunge1,KimaniGachuhi2,AnthonyEtyang1.1KEMRI Centre forGeographicMedicineResearch, Coast,KiIifi, Kenya; 2 KEMRI Centre forBiotechnologyResearchandDevelopment,Nairobi; 3KEMRICentreforClinicalResearch,Nairobi,Kenya;4KEMRICentreforMicrobiologicalResearch,Nairobi,Kenya;5KEMRICentreforPublicHealthResearch,Nairobi,Kenya;6

KEMRI-ESACIPAC, Grantsmanship,Nairobi, Kenya; 7KEMRI-Centrefor Respiratory Diseases Research,Nairobi;8MoiUniversity/WebuyeHealthandDemographicSurveillanceSystem

Objective:Theburdenofnon-communicablediseasesissignificant inKenyaandother lowandmiddle-incomecountries(LMIC).However,littleisknownabouttheassociatedcoststhatmaybeincurredbyhypertensivepatients.We conducted this study toexamine the costsofobtainingmedical care for hypertension in seekingprimary care in Kenyanhospitals (directmedical andnon-medical costs), the costs associated with being unable to work (indirect costs) and themagnitudeofthesecostsinrelationtohouseholdincome.

Methods: Responses gathered from hypertensive patients above 18 years of age attending aspecialisedoutpatientclinicataprimarycarehospitalwithatleastsixmonthsoftreatmentandsignedinformedconsentformweredoubleenteredandanalysed.Patientswereaskedtoreportcare seeking behaviour and expenditure related to accessing hypertension care. Family socio-economicstatuswasassessedthroughreportedhouseholdincomes.

Results: A total of 212 patients were interviewed. Eighty eight percent of patients reportedincurring costs to access care for any hypertension service or intervention. Themean annualdirect costwasUS$ 304.8(95%CI, 235.7–374.0)while themean annual indirect costwasUS$267.7(95%CI,238.6-296.8). The three highest direct cost categories were medicines (annualmean, US$ 168.9; 95%CI, 132.5–205.4), transport (US$ 126.7; 95% CI, 77.6–175.9) and usercharges (US$ 57.7; 95% CI, 43.7–71.6) making up 42%, 38% and 17% of total direct costs,respectively.Costsofhypertensioncareweregreaterthan10%ofannualhouseholdincomefor59% (95%CI,52.1.6-65.4) of patients interviewed. A greater cost burden was experienced byhouseholdswithlowersocio-economicstatuswithaconcentrationindexof-0.51(p<0.001).

Conclusions:Ourfindingsshowthatpatientsseekinghypertensioncare incursubstantialdirectand indirect costs. The out-of-pocket costs associated with obtaining care for hypertension


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imposesignificantbarrierstoaccess,particularlyforpatientsinthelowestwealthquintile.Thisillustratestheurgencyofimprovingfinancialriskprotectionforthesepatientsandstrengtheningprimarycarefornon-communicablediseasestopreventandmanagehypertensionillness.

Analysis of the costs of care for premature new-borns in Senegal

AngeKouassi,DakarIntraHealth

InthecontextofmystudyontheanalysisofthecostsoftreatingprematurebabiesinSenegal,mychoicewasmainlymadeinthecaseofthehospital‘‘HôpitalprincipaldeDakar’’.

Thishospitalappliesauniformrate(50,000CFAfrancs)perdayofhospitalizationtoalltypesofchildren received in the Neonatology department. To make my contribution, I opted for thecalculation of the costs, by the ABCmethod, for different types of premature babies, namelyverypremature,andveryprematureandlesspremature.

A two-pronged methodology was used to achieve my goals. The first one concerns datacollection and the second explains the ABC approach adopted. As specific data related to thetypes of children received in hospital are not available, I have adopted a data collectionmethodology. Data collection took place over two months and covered the population of allchildrenreceived intoNeonatology in2017.832caseswereanalysed, including292prematurecasesdividedinto34verylarge,95largeand163mediumprematurecases.TheinterviewwiththeNeonatologyDepartment, thequestionnaireaddressedtodoctors, thecaresupervisorandnurses,were developed. I have also read the documents available in the hospital and on theInternetrelatingtothecareofprematurebabies.

Thesecondmethodology related to theABCmethodconsisted firstly to identify theprocessesfor managing premature babies and to develop the dictionary of induced activities. Theresourcescommitted,andthedifferentinductorofresourcesandactivitieswerealsoidentified.Finally, the calculation of costs and their assignment to cost objects followed the explainedmethodology.Theresultsreachout277,961CFAfrancsforverylargepatients,and245,509CFAfrancs for large patients, and 202,495 CFA francs for premature patients per day ofhospitalization.Severalauthorshavefoundsimilarresults.

Based on the analysis of realities and costs found, some recommendations were made forpossiblereflectionsonpricing,guidanceforgrantapplications,advocacyandhospitalreporting.

Costs of adding rapid syphilis test to existing antenatal services at the primary healthcare level in Burkina Faso: a micro costing approach for prenatal diagnosis

FadimaYAYABOCOUM,InstitutdeRechercheenSciencesdelaSanté,Ouagadougou

Objective: To estimate the additional cost of an antenatal syphilis screening interventionimplementedinruralandsemiurbanhealthfacilitiesinBurkinaFaso.

Design:Amicrocostingstudyintheframeofaprepostimplementationinterventiongroupwithnocomparisongroupwasconducted.

Setting:Antenatalservicesin4primaryhealthcentersinhealthdistrictinBurkinaFaso

Population: Pregnant women attended to first antenatal care at the selected health facilitybeforeandaftertheintervention.


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Methods:Costsdatawerecollectedbeforeandafter implementationof theantenatal syphilisscreening in 4 selected health facilities in the healthcare perspective. Observations wereconductedthedayofantenatalcareintheantenatalcareroomconsultationwithallconsentingpregnantwomen.

Main outcome measures: Costs for antenatal care with and without rapid syphilis test wereestimated. Cost for woman screened and treated for maternal syphilis was also estimated.Results: Theaveragecost forunscreenedpregnantwomanwas$3.11(±0.14)andtheaveragecostforscreenedpregnantwomanwas$5.06(±0.16).Costdifferencebetweenunscreenedandscreened woman was $1.95. The main cost driver in screening was material costs. Syphilismaterialcostsaccountedonaveragefor16%to39%.

Theaveragecost forscreenedandtreatedpregnantwomanwas$6.28withbenzathinebenzylpenicillin (BBP) only and $9.41 for alternative treatment with erythromycin. Costs varied alsobetweenhealthfacilitylocationandprofileofhealthworker.

Conclusion Integrating point of care test for syphilis in ANC services is feasible at a modestincrementalcostincomparisonwithHIVtests.

Economic burden of type 2 diabetes mellitus complications among patients in the eastern region of Ghana: A descriptive cross-sectional cost-of illness study

AmonS.&AikinsM.,EcoledeSantéPublique,CollègedeSciencesdelaSanté,UniversitéduGhana

Objective:Toassesstheeconomicburdenassociatedwiththemanagementoftype2diabeteswithcomplicationsfrompatientsoftheEasternRegionalHospital’sDiabeticClinicoftheEasternRegionofGhana.

Methods:Thestudyisadescriptivecrosssectionalcost-ofillnessstudywhichwascarriedoutinMay, 2016 among 258 diabetes patients. Participants were selected by systematic randomsamplingand informedconsentwassigned.Apretestedstructuredquestionnairewasusedfordatacollection.ThedatawereenteredintoEpi-Infoversion7andanalyzedusingMicrosoftExcelversion 13 and STATA version 13. Kruskal-Wallis andWilcoxon Rank Sum tests were used todetermine statistical significance in cost difference. Total healthcare management cost wasestimated and average cost determined. Intangible cost burden was analyzed using the 5-dimensionLikertscaleandthetertiledescriptivestatistics.Sensitivityanalyseswasconductedtotestrobustnessofthecostestimates.

Results:About68%(n=175)oftype2diabetespatientswithcomplicationswereabove55years.The estimated total healthcare management cost was US$9,980.62, with direct healthcaremanagement cost constituting about 94%. The average healthcare management cost wasUS$38.68(95%CI:5.53-71.84).Patientsontreatmentfor5yearsandaboveincurredsignificantlyhigherdirectcostcomparedto thosebelow5years,US$40.03±40.71 (p<0.05).Patients incurmoderate intangible cost burden. There was no statistically significant relationship betweenintangiblecostburdenandallthesocio-demographiccharacteristicsofpatients.

Conclusion: The findings suggest considerable economic burden associated with healthcaremanagement of type 2 diabetes with complications, particularly in the elderly. The longer apatient stayswith thedisease, the significantlyhigheraveragedirect cost incurredpermonth.Diabetespreventionstrategiesand,patient’sregularphysicalactivitiesandproperdietaryplanarehighlyrecommended.

Costing analysis of salt iodine fortification in Ethiopia: preliminary results


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MINIMOD&EPHIEconomicsTeam:EliasAsfaw,JustinKagin,StephenA.Vosti,MulukenMoges,ZekariyasGetu

Background: Starting in the 1980s, different political, economic, and social factors havecontributedtothecurrentstateofthesaltmarketinEthiopiaaswellthecurrentconsumptionofiodizedsaltwithinhouseholds.

Rationale for the Study: Tounderstand the structureof the salt industry in Ethiopia and thecostsoffortifyingsaltwithIodine;includingstudyingsaltprices,thequotasystem,marketshareofsaltmanufacturers,aswellasthecostsoffortificationprograms.Itisalsousefulinassessingthe extent to which salt may be a cost effective delivery mechanism in the future for othermicronutrientsbesidesIodine.

Methodology:Micro-costing expenditures and a top-down costingmethodwere employed atthedifferent levels inthesaltmarketaswellasanalyzingthesalt iodizationprogramactivitiesand different contributions by the various stakeholders. The costing model was developeddepending on the salt market structure and a series of activities such as: a baseline survey,revision of salt standards, human resources, equipment and machinery, monitoring andevaluationbydifferentpartnersatdifferent levelsalong the implementationof thesalt iodinefortificationprogram.

Results:Thesalt industry is ingreatfluxandsubjecttotensionsandgovernment interventions(fixed prices). The fixed price ranges from Ethiopian birr/ETB 7.32 (United States Dollar/USD0.44)toETB8.71(USD0.52)dependingonthesourcesofrawsaltandtransportation.Thequotasystem was established by the Afar Salt Producers Mutual Support Association (ASPMSA) tobettercoordinatesaltproductionandsupply.TheAfarSaltManufacturingSCcontinuestoleadthe salt production and distribution (almost 65% of the total cost) followed by the SVS saltmanufacturer.Thetenyearstotal,2011to2020,inflationdeflatedcostofsaltiodinefortificationis ETB 81,302,875 (USD 4,858,920). Of these, the cost incurred at the salt factory (33%) andmonitoringandevaluation(32%)accountedforthelargestshare(>60%)ofthetotalcost.

Conclusions and policy implications: Iodine premix/potassium iodate and monitoring andevaluationarethemajorcostdriversinthesaltiodinefortification.EfficiencycouldbeimprovedthroughchangingtheM&Epracticesaswellaspossiblechangeinthesaltmarketstructureandpolicy instruments. Multiple-fortified salt could also be cost-effective for conveying othermicronutrientssuchaszinc,iron,folicacidandvitaminB12.

Assessing the Determinants of Cost Efficiency of Primary Health Care Facilities in Ghana: A Latent Class Stochastic Frontier Analysis

KwadwoArhin;GhanaInstituteofManagementandPublicAdministration(GIMPA)

Background: ImprovingUniversalHealthCoverage (UHC) to accelerate themarch towards theattainment of Goal 3 of the Sustainable Development Goals (SDGs) very much depends onenhancing the cost efficiency of primary healthcare (PHC) delivery in all developing countriesincluding Ghana. Estimating the cost efficiency as well as analyzing the determinants of costefficiencyofPHCfacilitiesisimportantinthemanagementofPHCfacilities.

Objective:Theaimof thisstudy is toestimatethecostefficiencyofGhanaianPHCfacilitiesaswellastoanalyzethemajordriversofcostefficiency.

Methods:Thestudywasconductedusingapaneldatastochasticcostfrontierwithlatentclasseswhich allows the data to construct different frontiers for each group and evaluation of cost


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efficiencylevelsiscarriedoutwithrespecttoeachgroup’sownfrontier.TheCobb-Douglascostfunctionmodelwasemployed.ThelatentclassmembershipanalysisisbasedonthehypothesisthatunobservabletechnologicalheterogeneityexistsamongGhanaianPHCfacilities.

Results:ThestudyresultsrevealthattherearethreestatisticallysignificantclassesinthesampleandthattheeffectsofthemajordeterminantsofcostefficiencyofaPHCfacilityareinfluencedbytheclassstructureofthatfacility.

Conclusion: PHC facilities could improve their efficiency levels substantially and that healthpoliciesfashionedtobringaboutimprovementinefficiencymustbeguidedbydifferentclassesidentifiedtoensuremoreaccurateandcost-effectivemanagementofresources.

Keywords: Primary Healthcare (PHC), stochastic frontier analysis, latent class, cost efficiency,Ghana.

An extended cost-effectiveness analysis of the AIDS Trust Fund in Uganda

CharlesBirungi,MSc1,2*,TimothyColbourn,PhD1,MarcosVera-Hernández,PhD1,3

1TheUCLCentreforGlobalHealthEconomics,UniversityCollegeLondon,UK;2UNAIDS,Botswana,3InstituteforFiscalStudies,UK

Background:HIVisadiseaseofinequality.Thisnecessitates“leavingnoonebehind”ifthe2030AgendaforSustainableDevelopment’sgoaltoendtheAIDSepidemicasaglobalhealththreatistoberealised.Currentglobalpolicydiscoursesonuniversalhealthcoverage(UHC)havefocusedattentionontheneedforincreasedgovernmentfundingforhealthcareinmanylowandmiddle-income countries. To this end, recognising that fast- tracking HIV/AIDS responses is key toprogress towards universal health coverage – owing to its significance in terms of fiscal andburdenofdiseaseterms–Ugandahas,since2014,approvedtheestablishmentofanAIDSTrustFund.ThegrowingcommitmenttoUHCnotwithstanding,thereispaucityofempiricalevidenceonhowdisease-specificfundingcanbeleveragedtoprogresstowardsUHC.Theobjectiveofthispaper is to empirically analyse how the AIDS Trust Funds can be leveraged for financingUHCthroughtheNationalHealthInsuranceScheme,includinganexplicitquantificationoftheensuinghealthandpovertyalleviationbenefitsanddistributionalconsequencesofthishealthfinancingpolicy.

Methods: To integrate equity and financial protection considerations into traditional cost-effectiveness analysis (CEA), this paper uses state of the art “extended cost-effectivenessanalysis” (ECEA). This provides a methodological framework of economic evaluation todeterminethedistributionalandfinancialriskprotectionconsequencesofUHCfinancingpolicyinUganda.Specifically,thebenefitsexploredspanoverfourdimensions:healthbenefits,directcosts, financial risk protection and, distributional consequence over income quintiles.Additionally, the basic principles that any decision rules should embody are articulated. Theincidence, health service utilisation and expenditure related to UHC per national incomequintileswasobtainedfrommultipledatasources.

Results:TheensuinghealthbenefitsoftheAIDSTrustFundinfinancingpriorityhealthprogramstowardsUHCandreducingout-of-pocket(OOP)expenditurearedistributedfairlyevenlyacrossquintiles.This,inturn,couldbringsubstantialhealthgainsandfinancialriskprotectionbenefits.However,povertyalleviationbenefitsareconcentratedamongthepoorestpopulationsgroups.Finally, the AIDS Trust Fund, as a revenue stream – in the absence of integration into healthfinancingsystems–mayresultininefficientspendingallocations.

Conclusions:Thispapercallsforanoverhaulofthehealtheconomist’smethodologicaltoolboxowing to two distinct features of the AIDS epidemic and response that make application of


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standardeconomicevaluationsmethodsaltogetherunsatisfactory.ECEAbuildsonstandardcost-effectivenessanalysis(CEA)inthreedimensions,allofwhichenhancetheabilityofstakeholderstoevaluatehealthfinancingpolicy.Themethodswedevelopedandemployedinthisstudycanthereforebeausefulapplicationinfurtheranalyzingpublicpolicyacrossawiderangeofhealthfinancing policy instruments and places. Also, this paper discusses the role of trust funds offinancingpriorityhealthprogramsinthepracticeofandthepolicydiscourseonthesustainablefinancingofUHC,andalsodraws lessons fromthenon-health-specific literatureonearmarkedtaxesandextrabudgetaryfunds.

Parallel session 1-4 Access to HIV-AIDS services

Discontinuation of anti-retroviral treatment: an empirical analysis of the determinants

KOUASSIKouassiJeanHugues,AlassaneOuattaraUniversity,Bouaké,IvoryCoast

HIV/AIDSisadeadlypandemicthathasclaimedthelivesofseveralmillionpeopleworldwide,inAfrica and in Ivory Coast. The socio-economic impact of AIDS and its consequences onindividuals, families and communities is extraordinary. Notwithstanding the considerableprogressmadeinthefightagainstthisdisease,thereisnovaccineordrugtopreventHIVortocureAIDS.

TheonlymedicallyavailablewaytotreatHIV/AIDSisusingantiretroviraltherapies.Thesedrugs,althoughhaving important sideeffects, produce conclusive results in reducing viral load to anundetectablethresholdandinstrengtheningtheimmunesystem.TheseARVsthusimprovethequality of life of patients, strengthen their health, prolong their lives and reduceAIDS-relatedmortality.

Inordertomakethesedrugsavailabletoallsocialstrata,manyincentivepolicieshavebeenputinplaceonaglobalscale.Thus,ARVshavebeenavailablefreeofchargesincethebeginningofthedecade2000.Ineconomictheory,incentivesareintendedtostimulateactorstoatargetedbehaviour. However, since the logic is the correct follow-up of ARV treatment in order toimprove health status, it has been observed that many people living with HIV worldwide,especiallyinIvoryCoast,areabandoningtheiranti-retroviraltreatments.Thesepeopleare,fromamedicalpointofview,called"losttofollow-up".In2011,IvoryCoasthad35%ofthoselosttofollow-up in itsHIVprogrammes. ThedroppingofARVsdangerously compromises therapeuticsuccess,alowcompliancerateconditionstreatmentfailure;itcreatesresistanceandpromotesviralreplication.Inaddition,thesepeoplewhoabandoncareruntheriskoftransmittinga"new"virusthatismoreresistanttoARVsandthereforemoredifficulttocontrol(Kouassietal.,2014).

This situation is a concern for health care providers and is generating interest in research inseveral disciplines, including economics, to explore the reasons why people abandon theirtreatment.Why do people livingwith HIVwho have been prescribed antiretroviral treatmentdrop out of treatment? This question aims to contribute to the understanding of thephenomenon of abandonment of care in the care of PLWHA. We conducted a descriptivestatisticalmethodologyanda simpleeconometric logistic regressionanalysisondatacollectedontwohundredandseventy-seven(277)PLWHApatientfilesattheBethesdaMedicalandSocialCentre,anHIVcarecentreinYopougon,Abidjan(IvoryCoast).


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The results of our analyses reveal a statistical link between the discontinuation of ARVs andsocio-demographicfactorssuchasgenderwhentheindividualismale,singlestatus,education,duration of treatment, square of treatment duration, non-participation in HIV status with arelativeanduseofdrugsofferedbytraditionalmedicinepractitioners.Thus,itisnotedthatmenareatahigher riskofabandoningcare thanwomen.There isa convex relationship (U-shapedrelationship)betweenthetimetakentotreatandthediscontinuationofARVs.TheprobabilityofdiscontinuingARVsdecreaseswiththedurationoftreatmentuptothefifthyearoftreatment.Fromthefifthyearoftreatment,individualsonARVsbecomewearyoftheheavinessandinfinitenumberofdrugs to takeandcanmisinterpret theirhealth status,allother thingsbeingequal,andtheprobabilityofleavingcareincreases.TheeducationallevelofpatientsisalsosignificantlyrelatedtothenotionofPOS.Themosteducatedpatientstendtoseekreferralhealthcentrestoinvalidateor confirm theirHIV statusand thereforeabandon theHIV servicesof theBethesdaMedical and Social Centre. Regardingmarital status, it is noted that single patients aremorelikelytoabandoncarethanpatientsinaconjugalrelationship.Asaresult,patientswhohavethecourage to share their status with a loved one have a greater chance of remaining in theantiretroviralcareprogramthanthosewhodonot.Finally, the results indicate that theuseoftraditionaldrugshasanegativeeffectontheretentionofPLWHAinantiretroviralcare.

Thus, two (2) basic hypotheses of this study are confirmed. The use of traditional medicalpractices has a negative impact on themaintenance of ARV care. Also, non-sharedHIV statuswitharelativeispositivelycorrelatedwithdiscontinuationofantiretroviraltreatment.However,the first hypothesis is rather invalidated. Contrary to what we thought, the most educatedPLWHAshaveahigherprobabilityofleavingcareandwethinktheywouldbeself-transferred.

In view of the above,we suggestmeasures such as: identification of the traditionalmedicinepractitionersproposingremediesforHIV,analysisoftheefficacyandrenaltoxicityandhepatitisof these drugs and the integration of those recognized as effective in the fight against HIV.However, itwillbeafiercefightagainstadvertisingandothermisleadingcommunicationsthatdivertpatientsfromconventionalHIVcare.It isalsonecessarytodematerializepatientrecordsby adopting digital registries and to centralize them in order to better control patientmovementsthroughoutthenationalterritory.Thiswillmakeitpossibletoavoiderrorsinfiguresrelatedtopatientswhohavebeenself-transferredbuthavebeendeclaredoutofsightbecausethey have not been seen again in health centres. In addition, there is also a need for a newapproach to HIV awareness. It will be a communication aimed at populations and especiallyPLWHA with the objective of informing them about the advantages of using ARVs and theireffectivenessintreatingHIV.Indeed,inthefaceofthemanyperverseeffectsandslowactionofARVs, some patients find refuge among traditional medical practitioners who promote theirproducts;thisfactkeepsthemawayfromARVs.Finally,patientsshouldbeencouragedtosharetheir serostatus; this will allow them to benefit from family support and thus to bear thepsychologicalloadofthedisease;supportthatisimportantinmaintainingcare.

Effective HIV Care and Support Interventions in Nigeria: A rights-based approach

Ifeanyi Nsofor*,AdaobiEzeokoli*,NanlopOgbureke***EpiAFRIC,Nigeria,**ChristianAid

BackgroundHIV-relatedstigmaanddiscriminationhavefar-reachingconsequences.PeoplelivingwithHIVandAIDSaredeniedtheirrights,disownedbytheirfamiliesandexperienceviolenceasaresult.Accesstohealth,economicandeducationalopportunitiesiscompromised.AlltheseinturnlimitHIVprevention,treatmentandcare.


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AimsandObjectivesTostrengthen,developandexpandeffectivecommunity-basedapproachestoensurethat:HIV-relatedstigma,discriminationanddenialischallenged,peoplelivingwithHIV(PLHIV)andtheirfamilieshavesustainableaccesstoqualitycareandsupportservices:qualityoflifeofPLHIVisimprovedandtheirrightspromoted.

Methods Quantitative and qualitative data collection methods which included desk-reviews,FocusGroupDiscussions,questionnaireadministrationsandKeyInformantsInterviews

KeyFindings IncreasedaccesstoqualitycareandsupportthroughtheHome-BasedCare(HBC)services (45% atmidterm evaluation to 81% at end-line). Savings and Loans Association (SLA)Welfarefundwasestablishedforsustainedhomeandhospital-basedcare,supportandaccesstotreatment. Improved sustainable livelihoods andnutritional status; SLAmembership increasedfrom57%atmidtermto88.5%atendline.Asteadydeclineinthelevelofstigma,discriminationanddenialwasreported(increasingfrom32%to86%).PLHIVcollectivelypushedforthesigningofthenationalanti-discriminationact.

MainConclusionsPLHIVbecomeincreasinglyresilient,therebyreducingthebarrierstoHIVcareand support and increasing access to quality HIV treatment options when sustainable rights-basedapproachesareused.

Determinants of regular demand for antiretroviral therapy in Togo

BagnanBato,UniversityofLome(PhDstudentinhealtheconomics)

Background: Irregular demand for antiretroviral (ARV) therapy is one of the reasons for thefailureofpeoplelivingwithHIV(PLHIV).This leadstothetransitiontothehigherlinesofARVswhicharemoreexpensiveandthereforecauseadditionalcostsofthesubsidytreatmentduetofreesince2008inTogo.Thenumberofunobserversincreasedfrom397in2014to1333in2015withover2045losttoTogo;despitethefreetreatment.ThispaperaimstodeterminethefactorsofregulardemandforARVtreatmentfromtheanalysisoftheutilityfunctionofthepatient.

Methodology:ThisstudyusedpatientmonitoringdatafromtheNationalAIDSControlProgram.Thestudyinvolved2497patientswhoinitiatedtreatmentbetween1Januaryand31December2017 in 42 treatment centers in Togo. From the microeconomic analysis of consumer carebehavior,weused the Logitmodel to analyze thenon-monetarydeterminantsof regularity atARVtreatment.

ResultsandDiscussion:ThemajorityofPHAshaveaprimaryeducation level (47%)orno level(25%).46%ofthemareatstage1oftheWorldHealthOrganization(WHO)against5%atstage4of disease. The majority are traders (35%) or unemployed (18%). Of 2497 patients, 32% areirregularatmonthlytreatmentappointments.Theageandprofessionalstatusofthepatientarefactors that have high probabilities of negatively influencing adherence to treatmentappointments.Patientswhohaveunstableprofessionalstatusgivelessusefulnesstotreatmentbecausetheyaremoreconcernedaboutthesearchforeconomicstabilitysincetheydonotyetmanifestthedisease.Ontheotherhand,theincreasingstageofWHOisafactorwhichpositivelyinfluencestheregularityattheappointmentsofrenewaloftreatment.Patientsinthiscasearemorehelpfulintreatmentwhentheybegintodevelopopportunisticinfections.

Conclusion: Despite the fact that ARV treatment is completely free, our results suggest theimplementation of close monitoring strategies targeting the socio-occupational categories ofpatientsandage.Itisalsoimportanttoworktoreducethenumberoftabletsperdoseandthesideeffectsoftreatment.Pleaseimprovethesocioeconomicconditionsofpatients.


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Factors associated with low uptake of HIV early infant diagnosis among the HIV exposed infant: Towards 90-90-90 target of 2020 in Harare City, Zimbabwe.

MasimbaChikowore,ChadambukaElizabeth,ChikakaElliot:AfricaUniversity

Background: HIV Early Infant Diagnosis (EID) done through DNA Polymerase Chain ReactionconstitutesanessentialpartofPMTCTfortheexposedinfants.TheWorldHealthOrganizationin2014 set the 90-90-90 target of the year 2020 recommending that at least 90% of the HIVexposedshouldknowtheir status,at least90%tohave therapyandat least90%tohaveviralsuppression. Harare City had 78%, 66% and 0% respectively of these targets in 2016. IinvestigatedfactorsleadingtolowuptakeofEIDinHIVexposedinfants.

Objectives: were 1. To determine the predisposing factors (knowledge, attitudes andperceptionsaboutEIDandPediatricART)thatareassociatedwithlowuptakeofEIDandTherapy2.Toestablishthereinforcingfactors(socialsupport)thatareassociatedwithlowuptakeofEIDandTherapyinHIVexposedinfantsinHarareCity.3.Todeterminetheenabling(Healthservicesrelated)factorsthatareassociatedwithlowuptakeofEIDandTherapyinHIVexposedinfantsinHarareCity.

Methodology:Anunmatched1:1casecontrolstudywasused.Studyparticipantswererecruitedusingsystematicrandomsampling.Intervieweradministeredquestionnaireswereusedtocollectdata.EpiInfoversion7wasusedtoanalyzedataforUnivariateandMultivariate.

Findings: Knowledge on the available EID services[OR=0.478,95%CI=(0.17;1.29),P-value0.141,marriedmothersOR=0.75,95%CI=(0.1904;2.9706), P- value0.7393],, and secondaryeducation [OR=0.19,95% CI=(0.0599;0.5792),P-value 0.0034 were statistically significant withmothers likely to take up early infant diagnosis hence protective. Factors associatedwith lowuptake of early infant diagnosis uptake were prohibitive religion [OR=14.47,95% CI(5.3739;39.0012)P-value <0.0001, lack of money for transport and failure to access healthservices. OR=13.096,95% CI(4.214;40.695)P-value <0.0001 Implications of the results wereindicatedandrecommendationsweremade.

Conclusion:ImprovementinEIDuptakewillhelpimprovelifeinexposedinfants.Furtherstudiesshouldbeonthe1.(KAP)knowledge,attitudesandperceptionsinregardtoEID,2.Thereisneedforastudyontheroleofculture,religion,cultureandsocial leadersinEIDservices.forHarareCitytomeetthe2020target.

To What Extent Can Task Shifting Reduce The HIV Prevalence in the MSM Population, Malawi

JoanneMartin,UniversityofAberdeenScotland-Aberdeen

Introduction: MSM in Malawi have a HIV prevalence (around 20%) that is twice that of thegeneralpopulation(9.2%).DespiteresearchidentifyingMSMasoneofthe‘high-risk’HIVgroupsinMalawi,work and research in this area has largely focused of heterosexual andmother-to-childtransmission.Taskshiftingisaprocessusedtoexpandhealthcareservicesbymovingtasksfromhighlytrainedandskilledhealthpersonneltothosewhoare lesstrained(e.g.communityhealthworkers).ThishasbeenusedinMalawitoexpandHIVtesting,counsellingandtreatmenthowever,ithadnotbeentargetedattheMSMpopulationthusfar.

Methods:A literaturesearchwascarriedoutusingMedline,EMBASEandPubMed.Keysearchterms were used. The search topics included: the strengths of task shifting and the sexual


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behaviours, attitudes and challenges faced by MSM in Malawi. Limitation criteria was set toensurethemostappropriateandrecentresearchwasreviewedandincludedinthisreview.

Results:The resultsobtainedsuggest that task shiftingmaybeused toovercomesomeof thebarriersfacedbyMSMbutitisnotcleariftaskshiftingcouldovercomeallofthem.Keythemeswereidentifiedandconclusionsweredrawnfromthesethemes.

Conclusion: The results indicate that there may be a role for Task Shifting in reducing theprevalenceofHIVinthishigh-riskgroup.However,fromtheresultsitisuncleartowhatextenttaskshiftingcandothisasthechallengesfacedarecomplex.

Antiretroviral dispensing groups as a measure to improve adherence: cost-effectiveness analysis in Zambia

James Simukoko,CatholicReliefServices,LusakaBackground:Zambiaisoneofthecountriesinsub-SaharanAfricawithhighHIV/AIDSprevalenceat13.34%.Thishasledtoanincreaseinthenumberofpeopleaccessingantiretroviraltherapy.Despite this, there is no corresponding increase in infrastructure and number of healthcareworkers.As a result, patientsmustwalk longdistanceand spend longwaiting times at healthcenters,oftencausingsometomisstheirpharmacyappointments.Concernsabout incompleteadherence among patients are an important consideration in expanding the access toantiretroviraltherapyinsub-SaharanAfrica.Thereisevidencethatdifferentiatedservicedeliverymodels, such as patient adherence groups, improve adherence to treatment and are costeffective.

Objectives: The study investigated the cost effectiveness of community adherence groups onadherencewhencomparedtostandardofcare.

Methods:Thestudyisacost-effectivenessanalysisfromthepatient’sperspective.Thestudywasacost-effectivenessanalysisfromthepatient’sperspective.

I.)Cost:Thecostoftransportwasabusroundtrip.Labourcostwerebasedonanaveragetimeof(6hrs).

ii.) Mean days for late pharmacy refill information was retrieved retrospectively. incrementalcost-effectiveness ratioswereobtained.Two-waysensitivityanalyseswereconductedoncostsand adherence. The study was conducted atMahatma Gandhi and Kasanda Clinics in centralZambia.

ResultsThetotalnumberofclientswas378.201onthestandardofcareand177onadherencegroups.TheaveragecostsperclinicvisitwasUS$4.02onthestandardofcaretcomparedtoonlyUS$0.7forclientsonintervention.Theaveragedayslateforpharmacyrefillforthestandardofcarewas4.18dayswhile thoseon the interventionwhere late foronly 0.19. The IncrementalCost Effectiveness Ratio was US$ -0.8 per one day improvement in adherence. One wasSensitivityanalysisshowedrobustnessinincrementalcosteffectivenessratio.

Conclusion:Itwastentimescostlierforpatientsonstandardofcaretovisittheclinic.Theywerealsomorelikelytobelateforrefills,comparedtothoseontheadherencegroups.Belongingtheadherence groupswasmoreeffective in reducing thenumberof days late for pharmacypick-ups.


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Parallel session 1-5 Access to maternal health services

Factors associated with late use of postnatal first assistance in a health facility after home delivery in Ivory Coast

TETCHIO1,2,YAPIA1,CoulibalyA2,KpeboD1,2,SabléSP1,2,EkouFK1,21:NationalInstituteofPublicHealth,Abidjan 2:MedicalSciencesTRU,Abidjan

Postnatalfirstaidisrecommendedforallwomenwithintwodaysofdeliverytoreducetheriskofmaternalandnew-borndeath.ThisstudyanalysesthefactorsassociatedwiththelateuseofpostnatalcareafterhomedeliveryinIvoryCoast.

Thedatafromthe2011-2012IvoryCoastDemographicandHealthSurvey(DHS-CI)wereusedasthebasisforthisanalysis.Thestudiedpopulationwasalllivebirthsathomerecordedinthelastfiveyearsprecedingthesurvey.Thedependentvariablewasthetimeelapsedbetweenbirthandpostnatal first assistance. A duration longer than 48 hours is considered as a delay. Theindependent variables are selected from socio-demographic data and pregnancy history. Abivariate and multivariate analysis using the binary logistic regression method identified riskfactorsfordelayinearlypostnatalcareafterahomebirthatthe5%alphathreshold.

Outofwholly3,462homebirths,1,490motherswerereceivedforpostnatalcare.Themothershadanaverageageof29yearsold.Aboutthreeoutoffourmothersandtheirspouses(65.5%ofcases)wereoutofschool.Theylivedin83%ofcasesinruralareasandbelongedtothepoororvery poor category of thewealth index. About prenatal consultations, 12.4%of births had noANC.Most births were attended by traditional birth attendants or community health agents.About50%ofmotherswerereceivedafter48hoursafterdelivery.Factorsassociatedwithdelayweresocio-economiclevel,decision-makingpowerinthehousehold,religionandthecategoryofworkerswhoattendedthebirth.

Thedevelopmentofastrategytoimproveaccesstopostnatalcareshouldconsiderthesefactors.

Assessing the cost of maternal postpartum services, before and after interventions in Burkina Faso

DanielleYugbaréBelemsagaa,b*,ResearchInstituteofHealthSciences,Co-authors Anne Goujonb,Olivier Degommec, Tchichihouenichidah Nassad, Els Duysburghc, SeniKouandaa,e,MarleenTemmermanc,faBiomedicalandPublicHealthDepartment,InstitutdeRechercheenSciencesdelaSanté,Ouagadougou;bWittgensteinCentreforDemographyandGlobalHumanCapital(IIASA,VID/OAW,WU),Vienna,Austria;c International Centre for Reproductive Health, Faculty ofMedicine andHealth Sciences, Department ofPublicHealthandPrimaryCare,GhentUniversity,Ghent,Belgium;d Direction générale des études et des statistiques sectorielles (DGESS), Ministère de la santé,Ouagadougou,BurkinaFaso;eAfricanInstituteofPublicHealth,Ouagadougou,BurkinaFaso;fCentreofExcellenceinWomenandChildHealth,AgaKhanUniversity,Nairobi,KenyaIntroduction: The Missed opportunities for maternal and infant health (MOMI) project hasimplementedapackageofinterventionsatcommunityandfacilitylevelstouptakematernalandinfantpostpartumcare (PPC).Oneof these interventions is the integrationofmaternalPPC inchildclinicsand infant immunizationservicesbasedontherationalethatamajorityofwomenbringtheirinfanttohealthservicesforimmunizationbutfewgetchecked.MaternalPPCentails


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monitoring the wellbeing, early detection and management of complications, preventivemeasuresandcounselling.

Aim: This paper assesses the economic cost ofmaternal PPC services, for health services andhouseholds,beforeandaftertheimplementationofinterventionsinKayahealthdistrict(BurkinaFaso).

Methods:WeusedBurkinaFasoNationalHealthAccountstoevaluatethecostofreproductivehealth services, in particular PPC in 2013, 2014 and 2015. Based on two household surveyscollectedbefore(N=757)andafteroneyear intervention(N=754)amongmotherswithinoneyear PP, we also estimate the household costs of maternal PPC visits by infant date of birthbeforeandafter the interventions implementation.Wecompare thePPCcosts forhouseholdsandhealthserviceswithorwithoutintegrationininfantimmunizationservices.Wefocusonthecostsoftheinterventionatdays6-10thatwasmostsuccessful.

Results:Reproductive health expenditures from all funding sources in Burkina Faso grew steadily since 2011 due to the implementation of the Millennium Development Goals and an increase in the subsidies for family planning. Theaverageunitcostofhealthservicesfordays6-10maternalPPCdecreased from4.6USDbefore the intervention in2013 (Jan-June) to3.5USDaftertheinterventionimplementationin2014.MaternalPPCutilizationincreasedwiththeimplementationoftheinterventionsbutsodiddays6-10householdmeancosts.ThecostsincreasedwiththeintegrationofmaternalPPC with BCG immunization.

Conclusion: The uptake of maternal PPC led to a cost reduction, as shown for days 6-10, athealth services level. Further research should determine whether the increase in costs forhouseholdswillbedeterrenttotheuseofintegratedmaternalandinfantPPC.

Key words: postpartum; maternal and infant health; health service costs; household costs;integrationofservices;BurkinaFaso.

Availability of emergency obstetric and neonatal care in West Africa: the case of Ivory Coast

*SimonePierreDjah,**DrPaulineABOU,*M.SekaATSE*MinistryofHealth,Abidjan,**UNFPA-CIVObjective: The study aims to provide to the policy makers and planners some up-to-dateinformation on health facilities offering EmONCs in order to carry out effective actions formothersandnew-borns.

Methodology: This is a rapid assessment of the availability of EmONCs needs. Data werecollected from November to December 2017 in the country's 20 health regions from referralfacilities and urban health centres. These were reconciled before the analysis tables wereproduced.

Results of the study: The profile of the health personnel is marked by a high availability ofmidwives present in 99%of the structures visited, StateRegisteredNurses (97%) andGeneralPractitioners (96%). On the other hand, the specialities are poorly represented in this casegynaecologistspresent in22%ofhealthestablishments,surgeonsandpaediatricians(with13%respectively)andFDImidwives(0.5%).

Of the 100 reference structures visited, 66 have at least oneoperating room, or 66%. 47%ofhealth centres have a room reserved forwomen in labour,more than 80%of health facilitieshaveadeliveryroomand42%ofhealthfacilitieshavealaboratory.


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ThelevelofavailabilityofECCRSservicesremainslow.Indeed,outof60expectedactualEONUChealth establishments, 11 structures offer the 9 signalling functions. In addition, 18establishmentsareSONUBemployeesoutofanexpected254.Gapsarethereforeobservedin49EONUCand236SONUBestablishmentsrespectively.

Twomainsignalfunctionsexplainthisinsufficiency,namelysuctioncupassistedchildbirth(14%)and neonatal revival (39%). In contrast, parenteral antibiotic administration and parenteraluterotonicadministrationare themost commonlyusedEmONCs functions,with91%and87%respectively.

Thelowavailabilityofeffectivefull-serviceEmONCsfacilitiesleadstolowutilizationofEmONCsservices. For example, the rate of deliveries in EONUC facilities is 3.5%, the caesarean sectionrate isestimatedat0.61%andtherateofsatisfactionofEmONCneedsis6.9%.Thereisalsoalackofqualityofcareprovidedthroughtheearlyintrapartumandneonataldeathrateof1.5%,the lethality rate of direct obstetric complications of 1.49%, the proportion of deaths due toindirectobstetriccausesof33.8%.

Social and economic determinants of under-five mortality in sub-Saharan Africa: the case of Senegal.

NDIAYEOumy,Economistedesanté/AssistantederechercheauCREA(Dakar/Sénégal) Childmortalityisakeyindicatorofchildwell-beingandhealth.Atthegloballevel,reportsfrominternational agencies indicate a rather alarming situation despite the remarkable progressnotedintheaftermathoftheSecondWorldWar,withunder-fivechildmortalityestimatedat5.9millionchildrenworldwide(SDGs Sustainable Development Goals,2016).Notwithstandingtheeffortsmade,sub-SaharanAfricaandSouthAsiaremainthemostaffectedregionsrespectively.Sub-SaharanAfricaaloneaccountsfor38%ofglobalneonataldeathsin2014.

InSenegal the situation ismoreworrying,particularly in the southern regions,whichhave thehighestmortalityratesaccordingtotheDemographicandHealthSurvey(DHS,2016).However,over thepast15years, the levelofchildmortality in thecountryhasdeclined,with the infantandchildmortality rate falling from91‰to51‰.Thedecline in theneonatalmortality ratehas been even slower, with 45% of deaths among children under five occurring during thisperiod.TheWorldHealthOrganization(WHO)recognizesthatthesedeathsarepreventable.

Based on data from the DHS (2016), this research is part of this perspective and aims todeterminethesocialandeconomicfactorsthatexplainunder-fivechildmortalityinsub-SaharanAfrica,takingthecaseofSenegalasanexample.

The results from the logistic regression estimation allowed us to discover that the economicstatusof themotheraswell asherempowerment in termsofoverallhousehold spendingaredeterminants of child health. Also, we see that the positive impact ofmaternal education onchildmortalityincreasesasthelevelofeducationincreases.Finally,child-specificcharacteristicssuchasgenderandnutritionarealsodeterminantsofunder-fivemortality.

Inthiscontext,theroleoftheauthoritiesistwofold:toadoptpoliciesandactionsaimedatbothmore accessible and continuous schooling, especially for young girls, and to promote theeconomicandfinancialempowermentofwomeninordertofacilitateaccesstohealthinputsformothersandchildren.


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Reaching Rural Reproductive Women in Kintampo, Ghana with Family Planning: Evidence from the EquityTool

KwameAdjei,IreneAzindow,AndreaSprockett,FelixOppong,YeeteyEnuameh,KwakuPokuAsante,NiraliChakraborty,SethOwusu-AgyeiKintampoHealthResearchCentre,MetricsforManagement

Introduction Family Planning (FP) is an important investment to achieve the SustainableDevelopmentGoals. It is also a recommendedpriority area formost sub-Saharan countries intheirquesttoachieveUniversalHealthCoverage(UHC).InGhana,useofFPremainslow(22%)asreportedinthemostrecent(2014)GhanaDemographicHealthSurvey(GDHS).

In Kintampo North and South districts, use of FP as last reported in 2013was 25.3%. Recentefforts to improve this in these districts was facilitated through an implementation researchknownastheContinuumofCare (CoC)Card forFamilyPlanning (2017).Themain interventionwastheCoCcard.Women(15-49)whocameforservicesontimewereencouragedusinggoldstars.

The EquityTool for Ghana was used to measure socio-economic status (SES) of CoC FPparticipants at project endline. The EquityTool is an easy to use set of questions and analysisguidance that simplifies the DHS wealth index questions by collecting a reduced number ofhighly significant country-specific questions. The tool benchmarks results to national or urbanwealthdistribution.Quintile1isthelowest(poorest)andquintile5thehighest(wealthiest).

Objectives

• ToidentifySESofparticipantssoastounderstandequityinFPuse• TodeterminetherelationshipbetweenwealthquintileandFPuseamongstparticipants(15-49)

MethodsWeconductedacrosssectionalsurveycarriedoutfromFebruarytoMarch2018usingResearchElectronicDataCapture(REDCap)withtheEquityToolquestionsincorporated.Womenofreproductiveage(15-49)weresampledusingtheKintampoHealthDemographicSurveillanceSystem,which covers predominantly rural communities in KintampoNorth and South districtswhere the CoC studywas implemented. The relationship between FP use andwealth quintilewas assessed with a logistic regression model controlling for the effect of other explanatoryvariables.

ResultsA total of 949women participated in the survey. Theirmean agewas 29 years (SD =9.97).Useof FPamongstwomenwas30.7%.Whenbenchmarked to thenationaldistribution,study participants were predominantly in quintile 3 (33.0%) and quintile 2 (26.5%). From theunivariate analysis, FP use was associated with an increase in wealth quintile. There was,however, no significant relationship between FP use and wealth quintile after controlling forotherexplanatoryvariablessuchasageandmaritalstatus.

Conclusion FPuse amongst participantswasnot dependent on SES. Tobetter achieveUHC inGhana,factorslikeagemustalsobeconsideredinFPprogramstargetedatpredominantlyruralcommunities

Socioeconomic inequalities in maternal health in Zimbabwe: the case of skilled birth attendance and antenatal coverage

ATLukwa1,JE.Ataguba11HealthEconomicsUnit,SchoolofPublicHealthandFamilyMedicine,FacultyofHealthSciences,UniversityofCapeTown,AnzioRoad,Observatory,7925


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Introduction Achieving equity in access to antenatal care (ANC) and skilled birth delivery arerecognisedasanessentialaspectsofprimaryhealthcare(PHC).This isalsoalignedwithglobaluniversalhealthcoverage(UHC)aspirations,whichentailsaccesstoqualityandaffordablehealthservicesforall.OneofthetargetsoftheMinistryofHealthandChildCare,Zimbabweistohavean organized health systems and an improved PHC system in a bid to better the chances ofattainingUHC.ZimbabweiscurrentlyestablishingnationalhealthinsuranceasafundingpoolforUHC.AlthoughantenatalcareandskilledbirthattendanceareessentialforUHCandinreducingmaternal mortality, disparities in maternal mortality between poor and rich in the world arestriking.

Objective To assess socio-economic inequalities in maternal health services in Zimbabwebetween2010-11and2015

Research methods This study uses data from Zimbabwe Demographic and Health Survey of2010-11and2015withrespectivesamplessizeof4,395and4,833womenaged15-49yearsandhadalivebirth5yearspriorthesurveyswereusedforthisstudy.Maternalhealthserviceswereassessed using skilled birth attendance and ANC coverage. Skilled birth attendancewas beingassistedbyadoctor,mid-wifeornurse.ANCcoveragewasdefinedwithhavingat least4ANCvisits. Wealth was assessed using asset/wealth indices. The concentration index was used toassesssocio-economicinequalities.

FindingsIn2010-11(and2015),about91%(94%)hadaskilledbirthdeliveryand66%(76%)hadat least 4 ANC visits. Between 2010-11 and 2015 socio-economic gap widened in maternalhealthservices.In2010-11(and2015)thepoorestquintiledecreasedby3.37%andincreasedintherichestquintileby5.15%fortheANCcoveragewhileskilledbirthattendancealsodecreasedin the poorest quintile by 4.27% and increased in the richest quintile by 5.22%. Theconcentrationindicesforskilledbirthattendancefor2010-11and2015were0.009(p<0.05)and0.013(p<0.05),respectively.Concentrationindicesforantenatalcarecoveragefor2010-11(and2015)were0.033(p<0.05)and0.027(p<0.05),respectively.

Conclusion Socio-economic gaps in the use ofmaternal health serviceswidened between thepoorand the rich.Results show that skilledbirthattendanceandANCcoveragewerepro-rich(i.e.favouringthewealthyorpeoplebelongingtohighersocio-economicclasses).ThereisaneedforpolicytoincreaseskilledbirthattendanceandANCcoverageamongthepoorinZimbabwe.

Access to maternal health services under the free maternal health policy in the Kassena-Nankana municipality of Ghana

PhilipAyizemDalinjong,FacultyofHealth,UniversityofTechnologySydney,AustraliaCo-authors:AlexYWangandCarolineSEHomer

BackgroundGhanaimplementedtheNationalHealthInsuranceScheme(NHIS)in2005toassistimproveaccesstohealthservicesandachieveuniversalhealthcoverage(UHC).Afreematernalhealth policy was implemented under the NHIS to enhance access for pregnant women. It isunclearifthepolicyhasreducedaccessbarriers.

Objective The study explored factors affecting access in terms of affordability, availability,acceptabilityandqualityofcare.

MethodsAstudywasconductedintheKassena-NankanamunicipalityofGhana.Itwasaparallelmixedmethods;collectedandcombinedquantitativeandqualitativedata.Questionnairewereadministered towomen (n=406)who gave birth in facilities and at home. In-depth interviews(IDIs)werecarriedoutwithproviders (n=25)and insurancemanagers (n=3),while focusgroup


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discussions (FGDs were held with women (n=10). Descriptive statistics were used for thequantitativedata.Thequalitativedatawereanalysedthematically.

Key findings AffordabilityWomenmadeout-of-pocket(OOP)payments,averagingGH¢17.50(US$8.90) and GH¢33.50 (US$17) at pregnancy and childbirth, respectively. About 36%(n=145/406) of women incurred what was classified as ‘catastrophic’ OOP payments, given a10%threshold.AvailabilityDistanceandtimewereabarriertocareseeking.Infrastructure,laboratoryservices,equipment and basic drugs were limited. The community-based health planning and servicescompoundswereparticularlychallenged.Ofthe14studyfacilities,onlytwo(14%)hadasourceofcleanwater,andfive(36%)hadaregularpowersupply.Emergencytransportforreferralwasalsounavailable.

AcceptabilityWomen perceived facilities to be clean despite the limitations in infrastructure.Providerswereperceivedtoberespectfulandfriendly.Sixty-sixpercent(n=234/353)ofwomenrevealedlackofprivacy,whichwasconfirmedinIDIs.

QualityofcareOverall,74%(n=300/406)and77%(n=272/353)ofwomenwereverysatisfiedorsatisfied with quality of care during pregnancy and at childbirth respectively, which wassupportedinFGDs.Providersreportedbeingdissatisfied,duetothechallengesassociatedwithserviceprovision.

MainconclusionsDespitethepolicy,OOPpaymentsstillexistedandone-thirdofwomenweresignificantlydisadvantagedbythesepayments.Mostwomenweresatisfiedwithcare,althoughthiscouldbebecausetheywereunawareofwhatqualityofcaremightinclude.Providerswereawareofthelimitationsofcareprovisionandmanyreportedbeingdissatisfied.Thegovernmentof Ghana, the NHIS and other stakeholders should embark on resourcing facilities as well asinfrastructuralimprovements.Thesewouldimproveaccesstoservicesandstaffsatisfaction,forachievingUHC.

Parallel Session 1-6 Economic evaluation of health programmes

Economic evaluation of the Family Health Team at the Primary Health Care Unit health facilities in Addis Ababa: Costing and Cost Effectiveness Analysis

EliasAsfaw1,FevenGirma2,MeseretMolla2,GenetMulugeta21 University of CaliforniaDavis (MINIMODProject) andTheChildren Investment Fund Foundation (SUREProgram),AddisAbaba,Ethiopia - 2FederalMinistryofHealth,HealthEconomicsandFinancingAnalysisTeam,AddisAbaba,Ethiopia

Background: The community Health Extension program packages were developed with thecentral philosophy of considering the community as the final end owners, producer andmultiplierofhealth.To improvehealthserviceaccess for theurbanpoor living incities/towns,family health team (FHT) was implemented to reach for the urban poor and economicallydisadvantageousgroups.

Objective:ThestudyaimstoassessthecostandcosteffectivenessofimplementingFHTservicedeliveryapproachfromtheproviders’perspective.


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Methods: Cost and effectiveness data were collected from five piloted health facilities (Gerjihealth center/HC, SelamHC, Entoto 2HC,Woreda 06HC andWoreda 12HC) in Addis Ababafrom thehealthcareproviders’ perspective.Costdata consistedof labor,medical supplies andmedicines, equipment, trainings, preparation and program management resources.Fouralternative service delivery strategieswere identified for the analysis: households/community,school, youth center and workplaces. Micro costing ingredient approach was employed tocomputetheactualcostofFHTatthehealthfacilitiessetting.Costperhouseholdandpercapitaper year was the final costing summary while incremental cost effectiveness ratio (ICER) wascomputedasnetcostperhouseholdreached.

Findings: ThecostofFHTperhousehold is8,726Ethiopianbirr(ETB)/391UnitedStatesDollar(USD)whichranges from448.66ETB(20.13USD)to41,019.06ETB(1,840.24USD). Percapitaperyearwasfrom72.70ETB(3.26USD)to2,474.40ETB(111.01USD)acrossthepilotedhealthfacilities. Themajor cost driverswere consumables and labor cost (accounting for 87%of thetotalcost)whilethelowestcostwasfortheprogrammanagementandcapitalresources.Inthebasecaseanalysis,implementingFHTwascosteffectiveattheICERofUSD28.45.ThecomputedICERforyouthcenter,schoolandhouseholdwereUSD4,622.28,USD50,082.08andcostsavingrespectively.

Conclusions: ImplementingFHTisacosteffectivestrategyintermsofreachingmorehouseholdat the low cost. Delivering the FHT service for the household is a cost saving strategy ascomparedtotheotheralternativemodalities(providingFHTfortheyouthcenters,schoolsandworkplaces). Scaling up the FHT in urban based health facilities is the most economical andfeasibleinterventiontoreachmoreurbanpoorandeconomicallydisadvantagedgroups.

Cost Effectiveness and Budget Impact of Fondaparinux for the treatment of Acute Coronary Syndrome (ACS) in Non-ST and ST Elevation Myocardial Infarction patients in the South African public health system

*TommyWilkinson,**AlexWinch,***KimMacQuilkan*UniversityofCapeTown,**ImperialCollegeLondon,***IndependentPublicHealthConsultant

IntroductionTheburdenofAcuteCoronarySyndromes(ACS)indevelopingcountriesisgrowing.ACScausesnearlyhalfofalldeathsduetocardiovasculardiseaseandsignificantlycontributestotheeconomicburdenonhealthcaresystems .ACScomprisesofUnstableAngina (UA),nonST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardialinfarction(STEMI).

Aim To assess the cost-effectiveness and budget impact of fondaparinux compared toenoxaparin and UFH in the treatment of NSTEMI and STEMI patients, and in addition tostreptokinaseforSTEMIpatientstreatedwithin6hoursofadmissionto informinclusionintheSouthAfricanStandardTreatmentGuidelinesandEssentialMedicineList.

Methods The assessment involved a cost-effectiveness analysis (CEA) and a budget impactanalysis(BIA).AMarkovcohortmodelwasdevelopedthatestimatedthelikelyclinicaloutcomesand costs associated with using fondaparinux compared to either enoxaparin or UFH in thetreatmentofNSTEMIpatients.InSTEMIpatients,fondaparinuxwithstreptokinasecomparedtostreptokinasemonotherapyifadmittedwithin6hours,andasanalternativetoenoxaparinandUFHifadmittedover6hours.

ResultsCost/QALYandbudgetimpactestimatesweregeneratedtoprovideanindicationofthecosteffectivenessandaffordabilityoffondaparinuxforthemanagementofACSpatients.


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The resultsare interpreted in thecontextkeyassumptionsused in theanalysis relating to thecontractprice thatcanbeachieved for fondaparinux,andextent towhichclinicalpracticeandoutcomesforACSreflectpivotalclinicaltrialoutcomes.

Conclusion TheuseofCEAandBIAallowscriticalmedicineutilisationdecisions to incorporatecostandaffordabilityconsiderations inadditiontoburdenofdisease,clinicaleffectivenessandsafetyprofile.

Economic burden of glaucoma on patients attending two health facilities in Tema Metropolis, Ghana

MatildaMadiweAdda1,JusticeNonvignon2,MosesAikins2,SamuelAmon2,GenevieveC.Aryeetey2

1.AchimotaHospital,OphthalmologyDepartment,AccraGhana2.UniversityofGhana,CollegeofHealthSciences,SchoolofPublicHealth.LegonGhana

Introduction: Glaucoma is the leading cause of irreversible blindnessworldwide. Ghana rankssecondintheprevalenceofglaucomaglobally.Glaucomaposesaconsiderableeconomicburdenon its patients since victims have to be on treatment for the rest of their lives. The cost ofmanagingglaucomaincreasesasthediseaseprogresses.Theevidenceonthecostandburdenofthediseaseonpatientsislimited.Thisstudythereforeaimstodeterminetheeconomicburdenofglaucomaonpatients.

Methods:A cross-sectionalCostof Illness (COI) study from theperspectiveof thepatientwasused.Thestudysample (n=180participants)wasdrawnusingproportionalsamplingtechniqueto select participants from a public and private eye care facilities in the TemaMetropolis. Asimple random sampling method was then used to select glaucoma patients from the twofacilities.Threemaincostswereestimatedoveraonemonthperiod.Directcost,wasthesumofmedical and non-medical costs related to the treatment of glaucoma. Indirect cost wasestimated using the human capital approach to determine patients and caregivers productivetimelostduetoseekingglaucomacare.Sensitivityanalysiswasperformedtodeterminechangesin total cost by varying variables that were uncertain. Intangible cost was determined usingtertilestatisticapproachtoassessfear,emotionalpain,socialisolationanddepression.

Results: The total cost of seeking glaucoma care from the perspective of the patient for bothfacilitieswasGHS45,889.28(USD10,525.06)withanaveragecostofGHS254.94(USD58.47)perpatient per month. The average direct medical cost for the private and public facilities wereGHS192.60 (USD 44.2) andGHS221.10 (USD 50.7) representing 78.8% and 82.7% of total costrespectively. Direct non-medical costwereGHS 36.34(USD 8.33) andGHS 29.41(USD 6.65) forprivate andpublic facilities per patient permonth respectively. Indirect cost (all facilities)wasGHS16.18(USD3.71)perpatientpermonth.Directcostconstitutedabout93.7%ofoverallcostand indirectcost6.3%of totalcost.Thecostestimatesweresensitive tochanges inwageandcostofmedicines.Patientsalsoexpressedlowtomoderateintangibleburdenofglaucoma.

Conclusion: Glaucoma poses a significant economic burden on patients. The direct costs ofglaucomaarehighandconstitutemore than two-thirdsof the total costofglaucomawith themaincostdriverbeingmedicines.

Economic implications of delayed review of reimbursement prices of tracer essential medicines on accredited health facilities in ejisu-juaben municipality, Ghana

PeterAgyei-Baffour(PhD)KwameNkrumahUniversityofScienceandTechnology,Kumasi,Ghana;PeterDarkwaGyasiNationalHealthInsuranceSecretariatGhanaHealthServiceHeadquarters,Accra


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Inmost developing countrieswhere themenace of poverty placesmajority of the populationbeyondthereachofqualityhealthcare,governmentshaveresortedto theuseofsocialhealthinsuranceschemesinaddressingfinancialgapsinaccessingcare.Fortunately,GhanaintroducedNationalHealthInsurancein2004tostepupeffortsatachievinguniversalhealthcoverageandaddressing gaps in health outcomes. However, infrequent reviews of the medicinesreimbursement prices to contain the fluctuating economic trends renders National HealthInsurance Authority’s (NHIA) reimbursement prices obsolete as quickly as they are set. Thisimpedesqualityhealthcaredelivery.Thisstudyevaluatestheeconomic implicationsofdelayedreviewofNHIAreimbursementpricesfortraceressentialmedicinesonNHIAaccreditedfacilitiesinEjisu-JuabenMunicipality,Ghana.Across-sectionalstudyinvolvingreviewofinventoryrecordsandinvoicesofpurchasesofthirty-fourtracermedicinesallowableatalllevelsofhealthcarewasdone retrospectively from March 2016-December 2016. A multi-stage cluster sampling wasdeployedtoinitiallyformclustersofhealthfacilitiesbasedonownershiptypesofpublic,privateand mission facilities. Consequently, fifteen facilities were selected through simple randomsamplingfromasub-clusteroffacilitiesformedwithinthemainclustersbasedonlevelofcareofthe facilities.Quantitativemethodwas used to assess per capita loss onmedicines dispensedwhilethequalitativemethodexploredproviders’perceptionsoneconomicimplicationsofpricedifference on pharmaceutical care. Data were analysed using Stata software version 12 andMicrosoft Excel Version 2013. Sensitivity analysis was done to assess the robustness of theestimatesovertime.WhileProvidersassertedthatpricedifferenceinpharmaceuticals leadstoloss of clientele, the study established a net per capita loss on the medicines surveyed inmajority(8in10)ofpublicandprivatefacilities.Majority(6in10)ofthemission-ownedfacilitieshaveanetpercapitagainonthedispensingofsamemedicines.Generally,themeanpercapitaloss isnotstatisticallysignificantamongthevariousfacilityownershiptype(F{2,12}=2.710p-value=0.107).

Therefore, National Health Insurance Authority’s reimbursement prices for tracer essentialmedicines leads to net per capita loss on revenue generation and De-capitalization of therevolving drug fund in private and public health facilities. Frequent reviews or indexation ofreimbursementmaybehelpful.

Parallel session 1-7 Data for management and policy making

What do we need to know? Data sources to support evidence-based decisions using health technology assessment in Ghana

DrSamanthaHollingworth,SchoolofPharmacy,UniversityofQueensland,Brisbane,HollingworthS,OdameE,DowneyL,RuizF&ChalkidouK)EmmanuelOdame,MinistryofHealth,GhanaLauraDowney,FrancisRuiz,KalipsoChalkidou,iDSI,ImperialCollegeLondon Background Health technology assessment (HTA) provides a framework to integrate multiplesourceofinformationincludingclinicalandeconomicevidence,andsocialvaluejudgements,tosupport healthcare priority setting. Ghana ismoving towards universal health coverage (UHC)andaNationalHealthInsuranceScheme(NHIS)wascreatedin2004.Themajorchallengefacingthe scheme is the financial sustainability if its operations. HTA is seen as an importantmechanismtosupportUHCobjectivesandtheNHIS,andtheGovernmentofGhanaiscommitted


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to institutionalisingHTA. An important aspect of the effectiveness of HTA is the identificationanduseoflocallyrelevantandhighqualitydatatosupportcontext-specificdecisionmaking.

AimToidentifyanddescribethesourcesandqualityofaccessibledatatosupportHTAinGhana.

MethodsWeusedanexisting framework todescribedata sources inGhanaencompassing sixdomains:clinicalefficacy;costs;epidemiology;qualityoflife;serviceuseandconsumption;andequity. We identified and described data sources using existing knowledge, views ofstakeholders,andsearchesoftheliteratureandinternet.

KeyfindingsThedatasourcesforeachofthesixdomainsvariesinextentandquality.GhanahasseverallargedatasourcestosupportHTA(e.g.DemographicHealthSurveys,BurdenofDiseasestudy etc.) which have rigorous quality assurance processes. There were few accessible datasources for costs, and resource utilisation. The NHIS is a potentially rich source of data onresourceuseandcostsbuthasaccess limitations.Therearealmostnodataforthedomainsofhealth-relatedqualityoflifeandequity.WenoteddatagapsandsuggestwaysHTAproponentsmayovercomedatalimitationsinavailabilityandquality.

ConclusionsWe have identified a number of key HTA-related data gaps to support decisionmaking in theGhanaiancontext.Althoughmoredataarebeingmadeavailable formonitoring(e.g. data for SustainableDevelopmentGoals), thesemaynotbe adequate to informHTAnoravailableindisaggregatedformtoenablespecificanalyses.Wesupportrecentinitiativesfortheroutinecollectionofcomprehensiveandreliabledatathatiseasilyaccessible(e.g. inelectronicformat)forHTAusers.AcommitmenttoHTAwillrequireconcertedeffortstoleverageexistingdatasources,forexamplefromtheNHIS,anddevelopandmaintainnewdata(e.g.localhealthutilityestimates).

Measuring wellbeing using the Women’s Capabilities Index amongst women involved in high-risk sexual behaviour in Kampala, Uganda,

GiuliaGreco,KennethRogerKatumba,JanetSeeley

Thereisagrowingdebateontheinadequacyofstandardoutcomemeasuresforevaluatingthebroadimpactsofhealthpromotioninterventionsonpeople’slives.

ThisstudyispartofaprojectthataimsatadaptingtheWomen’sCapabilitiesIndextoadifferentcontext (Uganda), inorder toproduceamultidimensional capabilitiesmeasure foruse in low-andmiddle-incomecountries.Theprocessofadaptationofthemeasureincludesanexplorativephase for assessing the extent to which the list of capabilities generated for the Women’sCapabilities Index is valid in a different low-income setting (Uganda) and therefore with thescopetobemorewidelyapplicable.ThelistofcapabilitiesintheWCIincludes:physicalstrength,innerwellbeing, householdwellbeing, community relations, and economic security. Given thesimilaritieswithotherlistsofdimensions,itisexpectedthatthelistofcapabilitiesforwomeninUgandawillhavea significantdegreeofoverlapwith the listgenerated forwomen inMalawi.Whatislikelytochangeistheidentificationoftheindicatorsformeasuringthecapabilities.Thespecific objective of this study is to develop a list of capabilities for the female populationsuitableforuseinalow-incomesetting,usingaparticipatoryapproach.

TobeconsistentwithSen’stheory,theselectionofcapabilitieswasconductedinaparticipatorymanner using focus group discussions. The focus group discussions have two objectives: a) toexplorelocallyrelevantconceptsofqualityoflife,dimensionsofwellbeing,valuablebeingsanddoings;andb)toexplorethevalueandrankofthedifferentconcepts.Weran10focusgroups,with10–12participantseach.TheparticipantsarewomenattendingtheMRCGoodHealthforWomenclinic inMengo,Kampala.Womenminorofagewereexcluded.Two-stagerandomised


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cluster sampling was used to select participants. Data collection took place from October toDecember2017.

Analysis is currently under way and will be completed by December 2018. Findings will beelicitedbasedonmanualframeworkanalysis.Frameworkanalysisusesathematicapproach,butallows themes to develop both from the research questions and from the narratives of thediscussions.Thereisstillalotofworkthatneedstobedoneinordertousewellbeingmeasuresin policy analysis. Some advances are taking place in the UK, but very little in low-incomecountries, where there is a great need for using comprehensive measure of progress, sincedevelopmentinterventionsinparticulararelikelytoaffectseveralaspectsofpeople’slives.ThewellbeingmeasuredevelopedandtestedinUgandawillbereadytobeusedalongsidetrialsfortheevaluationofpublicinterventions.Thismeasurewillbeabletoprovideabroaderpictureofthe effects of complex interventions such asmental health programmes,which are not easilycaptured with standard evaluation techniques. While the measure is intended to supportevaluators in low-income countries, the methodology developed in this study will also be ofinterest for researchers and policy makers in middle and high-income countries since it willcontributetotheglobaldebateonhowtomeasureprogressinsociety.

Key terms: Capabilities,Multidimensional, Index, qualitativemethods, focus group discussion,participatorymethod,women,Uganda,low-income

Collecting health facility and patient medicine information through telephone interviews in Kenya: A validation study

AshigbiePaulG*.,RockersPeterC.,LaingRichard,WirtzVeronikaJ.DepartmentofGlobalHealth,BostonUniversitySchoolofPublicHealth

Background: High cell phone ownership in low- and middle-income countries presents anopportunity for efficient data collection through telephone interviews both for surveys andregularsurveillance.

Objective:Thisstudyaimstovalidateamethodforcollectinginformationonhealthfacilityandpatientmedicinesthroughtelephoneinterviews.Wealsoexploreperceptionsofdatacollectorsandrespondentsonthemethod.

Methods: Data on the availability and prices of medicines at 137 health facilities and 639patients with non-communicable diseases were collected in September 2016 via in-personinterviews duringwhich respondent’s telephone numberswere also collected.Medicine priceand availability datawas collectedmonthly through structured telephone interviewswith 122health facilities and 130 patients between December 2016 and December 2017. Anunannounced in-person interviewwas conducted with respondents to validate the telephoneinterview within 24 hours of the phone-based interview. A bottom up itemization costingapproachwasused toestimate costs from theperspectiveof researchers. In-depth interviewswere conducted with data collectors and a 15% subsample of telephone surveillancerespondents.Agreementbetweendata collectedover thephone anddata collected in-personwasestimated.QualitativedatawasanalyzedthematicallyusingNVivo11QSR.

Findings:Themeanresponseratefortelephoneinterviewswithhealthfacilitieswas88.2%.Forhouseholds the mean response rate was 94.5%. Telephone interviews with facilities andhouseholdstook30.3minutesand12.8minutes,respectively,comparedto14.1minutesand8.5minutesfor in-personinterviews,respectively.Medicinesavailabilitydatashowedastatisticallysignificant agreement between data collected through telephone and in-person interviews athealthfacilities(kappa=0.9019;CI0.8848-0.9189)andhouseholds(kappa=0.4931,CI:0.3877-


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0.5984). The correlation of price of medicines from telephone and in-person interviews wasstatistically significant at health facilities (r=0.9; p<0.0001) and households (r=0.52, p<0.0001).The cost per phone interview at health facilities and households were $19.28 and $16.86respectively, compared to $186.20 for baseline in-person interview. Participants identified theabilitytophysicallyconfirmresponsesforin-persondatacollectiontobeanadvantageandpoorroad networks and the high level of effort involved in travel as disadvantages. Telephoneinterviewswereregardedastakinglessresourcesincludingcostandtime.

Conclusion: This studydemonstratedhigh response rates andhigh validity for telephonedatacollection.Incountrieswithhighcellphonepenetrationthemanyadvantagesoftelephonedatacollectionshouldbeconsideredindesigningstudiesonmedicinepriceandavailabilityandotherhealthsystemperformanceindicators.

The role of Information Technology in maximizing PHC HRH Governance in Kaduna State, Nigeria.

AgbonkheseOaiya,Dr.UmmulkhulthumBajoga,Dr.RotimiOduloju,Dr.LayiOlatawura:HealthStrategy&DeliveryFoundation

Background: The Nigerian Government plans to achieve Universal Health Coverage byrevitalizing Primary Health Care (PHC). One of the main challenges facing the PHC sector isinadequate and inequitably distributed workforce. PHC is the first level of care, but it isfragmented under different Government Agencies. The Primary Health Care Under One Roof(PHCUOR) policy focuses on centralizing human resources for health (HRH) governance,management,andplanningunderoneauthority;thePrimaryHealthCareDevelopmentAgency(PHCDA),however,implementingthispolicyhasbeensub-optimalduetotheabsenceoftimelyand accurate HRH information. Using Kaduna state as a case study, a thought-out process tostrengthenHRHgovernanceandstimulateevidence-drivendecisionmaking in thePHCDA,wastoonboardallPHCworkforceinaState-drivenfinancialmanagementsystem.

Aims and objectives of the research:Toachieve this,we conducted this research tohelp theAgency govern, manage and plan better for its workforce by developing an HRH InformationSystem.

Methods used: We conducted desk reviews of the all relevant policy documents to obtaininformationon theHRH landscape in theState. Then,weengagedvarious stakeholders in theStatetodeveloparoadmaptobridgethegaps identifiedbythedeskreview.Adatacollectiontool was developed and data on the sociodemographic, educational background andemploymenthistorywereextractedfromthephysical files.DatawereanalyzedwithMicrosoftExcelandpresentedaschartsandtables.

Key findings A total of 6,110 PHC staff were transferred to the PHCDA, of which 53% werefemale.Ofthetotalworkforce,70%werebetween31–50years;31–40years33%and41–50years 37%. The PHCworkforce is predominantly CommunityHealthWorkerswith 39%; CHEW22%,HealthAssistant/Attendant29%,JCHEW11%aretheleadingprofessions.Bytheyear2020,anestimated5%shouldbeexitingthePHCworkforce.

Main conclusions Findings from the researchhighlight thecurrentdistributionand skill-mixofthe PHC workforce transferred from the LGA, in accordance with the PHCUOR mandate.However, further staff verification is required to sanitize the PHC workforce. The findingsinformedtheStatePHCDAtoprioritizerecruitinganddistributingskilledofficerstoimprovetheavailabilityandqualityofhealthcareservicesinunderservedlocations.


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ParallelSession2

Organizedsession

OS 02 – Toward Systematic Approaches for Addressing Ethics & Equity Considerations in Health Technology Assessment

Organizer:InternationalDecisionSupportInitiative(iDSI) MohamedGad,GlobalHealthandDevelopmentGroup,SchoolofPublicHealth,ImperialCollegeLondonSpeaker:CarleighKrubiner,CenterforGlobalDevelopment,

UniversalHealthCoverage(UHC)—ensuringtheavailabilityofquality,affordablehealthservicesforallwithout financialhardship— isakeypolicyobjective formost countries,with renewedglobalcommitmenttoUHCinlow-andmiddle-incomecountries(LMICs).However,ascountriesworldwide explore health system reforms to progress toward UHC, policymakers facechallenging,morallycomplexdecisionsaboutwhatandwhomtocoverwiththeirlimitedhealthbudgets.Becausepriority-settingisinherentlydrivenbyvalues,anddecisionsaboutwhetherornot tocoverahealth interventionhaveethically importantconsequences for those inneedofservices,anethicsframeworkforpriority-settingcanbeacriticaltooltoinformbetterdecisionmaking for health on the path to UHC. Attention to clearly defined ethics commitments canimprove the design and delivery of a health benefits package across the entire policy cycle,including: settingstrategicgoals forUHCreforms, selecting thesetofhealthservices tocover,andmeasuringimpactsonethicallyimportantindicators—suchasequity.

ThispresentationwillprovideanoverviewoftheEthics&Equitychapter in“What's In,What'sOut:DesigningBenefits forUniversalHealthCoverage.” The chapteroffers a how-to guide forcountriestodevelopethicsframeworksforpriority-settingtailoredtotheirspecificcontextsandpolicyobjectives.Thesessionwillcoverarangeofethicscommitmentsthatcountriesmaywanttoadoptas theypursueUHCgoals.Thesemay include:addressingvarious typesof inequities,optimizing value-for-money through efficient health spending, enhancing evidence-baseddecision-making,andassessingtohowcoveragedecisionsmayaffectotherimportantaspectsofwellbeing not directly related to health— such as social relationships, respect, and financialprotection.Thesessionwillalsocoverthekindsofevidenceneededtoconductethicsanalyses,and howmonitoring, evaluation, and learning activities forUHCpolicies and programs can bedesignedtoenhancetheevidencebaseandtrackprogressonimportantethicsdimensions.

Speaker:MohamedGad,GlobalHealthandDevelopmentGroup,SchoolofPublicHealth,ImperialCollegeLondon

Over the past two decades, there has been a steady increase in applying health technologyassessment(HTA)tosupporthealthdecision-making.Althoughethicshasbeenarticulatedasa


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core component of HTA from the start, and many ethics frameworks exist in the academicliterature, there are still few examples of practical and systematic inclusion of ethics analysisthroughouttheHTAprocess.

Thispresentationwill serveas an introductorypiece, layingground fordeeperdivesonethicsframework available in international literature, as well as, the nature and extent of ethicalconsiderations inherently captured in fundamental principles of welfarist and extra-welfaristapproaches, underpinning the practice of economic evaluation frequently used in the HTAprocess.Weaimtoemphasisethespecificimpactonequityamongotherethicalconsiderations.

Furthermore,weprovideexamplesof variousapplications for systemic incorporationofethicsanalysis in theHTAprocess.This includesextensionstocurrentdecisionanalysis toolssuchas:ExtendedCostEffectivenessAnalysis(ECEA),DistributionalCost-EffectivenessAnalysis(DCEA),asmeans to break down and assess the social distribution of costs and benefits of healthcareinterventionsonthetargetpopulation.WefinallyprovideaquicklookatMulti-criteriaDecisionAnalysis(MCDA)anditsusesindecisionanalysis.

Speaker:RobBaltussen,RadboudUniversitymedicalcenter

Priority setting in health care has been long recognized as an intrinsically complex and value-laden process. Yet, health technology assessment agencies (HTAs) presently employ valueassessment frameworks that are ill fitted to capture the range and diversity of stakeholdervalues and thereby risk compromising the legitimacy of their recommendations.We propose“evidence-informeddeliberativeprocesses”(EDPs)asanalternativeframeworkwiththeaimtoenhancethislegitimacy.Thisframeworkintegratestwoincreasinglypopularandcomplementaryframeworks for priority setting: multicriteria decision analysis and accountability forreasonableness. Evidence-informed deliberative processes are, on one hand, based on early,continuedstakeholderdeliberationto learnaboutthe importanceofrelevantsocialvalues.Onthe other hand, they are based on rational decision-making through evidence-informedevaluationoftheidentifiedvalues.

EDPsdistinguishfivekeystepsinHTA:stakeholderinvolvement,scoping,assessment,appraisal,and communication & appeal. Based on experiences of HTA agencies around the world, theframework provides best practices on each of these staps. EDPs should not be considered ablueprintforHTAagenciesbutratheranaspirationalgoal—agenciescantakeincrementalstepstoward achieving this goal. The session presents the recently publishedmanual on EDPs, andseveralcountrycase-studieswhereEDPsareimplemented.

SusanGoldstein,PRICELESS-SA,WitsUniversitySchoolofPublicHealth

Background:SouthAfricahastakenstepstodevelopandimplementNationalHealthInsurance(NHI), with expressed commitments to developing a Health Technology Assessment (HTA)process. Although ethics has long been stated as a core component of HTA, andmany ethicsframeworksexistintheacademicliterature,therearestillfewexamplesofpractical,systematicinclusionofethicsanalysis inHTAprocesses.Furthermore,manyexistingframeworkswerenotdevelopedwithlow-andmiddle-incomecountrycontextsinmind–andmaynotbesuitedtothespecificcontextandchallengesofpriority-settinginSouthAfrica.

Aim:The South African Values and Ethics for UHC (SAVE-UHC) project is supporting thedevelopment of an engagement-driven, context-specified ethics framework for NHI priority-setting.


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Methods:Theapproachtodeveloptheethicsframeworkincludes:(1)policydocumentanalysis,includinglegislativematerialsandconstitutionalcourtdecisions;(2)literaturereviewofexistingethics frameworks for priority setting andHTA; and (3) three in-person consultationmeetingswiththeWorkingGroupinvolvingfacilitateddiscussionsandcasestudies.

Findings:The preliminary framework emerging from this process includes attention to variousdimensions of equity, cost-effectiveness, respect, ease of suffering, impacts on socialrelationships, financial protection, and social solidarity& cohesion. Phase II of the projectwillassesstheframework,applyingittohealthinterventionsbeingconsideredforcoverage.

Dr.SripenTantivess,SeniorResearcher,HealthInterventionandTechnologyAssessmentProgram(HITAP)

Thailand achieved universal health coverage (UHC) in 2002 when it introduced the UniversalCoverage Scheme (UCS). Since 2007, health technology assessment (HTA) mechanisms havebeendevelopedtodefinethebenefitspackagefortheUCS.

The objective of this presentation is to show how equity concerns have been addressed inThailand as it sought to extend health coverage to its entire population. This will be shownthroughaseriesofreal-worldexamplesofdecisionsmadeoverthelastdecade.

The principal mode of incorporating equity is through a participatory technology appraisalprocess, whereby different stakeholders are involved in setting the policy agenda, as well asadoption and implementation of the UCS coverage policy. Explicit criteria are used to selecttopicsforassessmentforthebenefitspackage,oneofwhichistheimpactoftheinterventiononequity. Furthermore, the country’s process guidelines for HTA enshrine the principles forstakeholderengagement,namely,transparency,accountabilityandparticipation.

Areviewofstakeholders’proposalsoninclusionoftechnologiesinthebenefitspackageovertheyearssuggeststhatcivilsocietyorganizations,patientgroupsandlaypeoplerequestedtheUCSmanager to subsidizenew technologiesandalsoaddress the issueof inaccessibility toexistingservicesamongvulnerablepopulations.Itisalsofoundthatwhiletheoutcomemeasuresofcost-effectiveness and budget impact analyses have been critical inputs in the decision-makingprocess,insomeinstances,thefinaldecisionhasbeenmadebasedonsocialvaluejudgements.For example, renal dialysis, a cost-ineffective intervention, was introduced into the benefitspackagetakingintoaccountthehigheconomicburdenofthetreatmentonhouseholds.Anotherexample is that of the life-saving treatment of Gaucher’s disease, a rare genetic disorder, forwhose treatment the drug imiglucerace was not cost-effective. However, because of the lowprevalenceandthehighcosttohouseholds,itwasdecidedthatthedrugbecoveredbytheUCS.Inboth cases, additionalmeasureswere implemented suchasoffering incentives toprovidersfor switching to the preferred intervention in the case of renal dialysis and setting up specialarrangementswiththemanufacturerofimigluceraceinordertomanagethebudgetimpactontheexchequer.

The Thai experience of incorporating equity in HTA thus underscores the importance ofstakeholderengagementduringthepolicyprocessinasystematicmanner.


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ParallelSession2

Oralpresentations

Parallel Session 2-1 Universal Health Coverage UHC Monitoring and evaluation

Supply side readiness for Universal Health Coverage: Assessing the service availability and depth of services in remote and fragile district of India.

VeenapaniRajeevVerma&ProfessorUmakantDash:IndianInstituteofTechnologyMadras Background: UHC is conceptually straightforward; translating it to a feasible metric is quiteintractable.Generalizablemetricsuchasservicereadinessindexisparamountasitcanindicatethecapacityof facilities toprovideessentialcareandfurthermore,estimationofmetricatsubnationalisimperativeforeffectiveevidencebasedpolicy.

StudyArea:CasestudyisconductedinremotestdistrictofJammuandKashmirstateinIndia.Itisfragileareawithheavymilitarydeploymentas it isboundedbyLineofControlwithPakistanand is embroiled in militancy and cease fire violations. Also, it is bearing brunt of doublewhammyof geographical inaccessibility due tomountainous topography and backwardness intermsofHumanDevelopmentIndicators.

Objective: The objective of the study is to evaluate the service availability and readiness ofhealthfacilitiesandascertainthesupplysidebarriersinserviceprovisioning

Methodology:Mixedmethod design via concurrent triangulation is employed. Facility surveyencompassing138facilitiesatvarioushierarchiesconductedtoascertainsupplysidereadiness.CompendiumofchecklistdesignedintandemwithWHO’sSARAmethodologyconjunctionwithIPHS standards. Information elicited by canvassing questionnaire and scorecard generated foreach facility. Health service readiness index calculated via amalgamation of average scoresacrosssixdimensions.Further,multidimensionalstatisticaldatareductiontechniqueofprincipalcomponent analysis employed for parsimonious composite indices. Stakeholder analysisconductedfornuancedqualitativeinformation.Myriadtechniqueslikekeyinformantinterviews,discussionsandFGD’sconductedwithvariousplayerssuchasleaders,adoptersandlaggards.

Result:Basicamenities,infrastructure,medicineavailabilityweresuboptimalinhealthfacilities.Readiness score of health facilities was 0.47 and 0.50 for medicine and basic amenitiesrespectively.Scoresforavailabilityofequipmentanddiagnosticcapacitywerelow0.57and0.53respectively. Service provisioning (adolescent health, delivery, neonatal and child health, non-communicable etc.) ranged from 0.47 for newtype Primary health centers with rudimentaryinfrastructureto0.71fordistricthospital.Firsttwocomponentamongstsecondarycarefacilitiesexplained 38% common variance characterized by service provisioning. For primary healthcenters,singleprincipalcomponentexplained24%commonvariancecharacterizedbynewborncare. Lack of incentives for retention in remote and shelling prone areas for staff members,


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unavailabilityofstaffquarters, inaccessibilityofroads,political interferencesandprevalenceofinternaladjustmentsintheformoftransfer/attachmentofhealthworkers,inhibitionsofskilledstaff in servingmilitancy prone areas, nonchalant attitude of policymakers identified asmajorbarriersforserviceprovisioningbasedonstakeholderanalysis.

Does affordability matter? Examining the trends and patterns in healthcare expenditure in India

RinshuDwivediBHUBANESWAR:RegionalMedicalResearchCentre,ICMR JalandharPradhan:NationalInstituteofTechnology,Rourkela,OdishaIndia

Rationale: Universal health coverage is among one of the major targets of SustainableDevelopment Goals, which stresses upon the availability, accessibility, and affordability ofhealthcare services without any financial risk to the households. Absence of better financingmechanismresults intoOutofpocketexpenditureandcatastrophe, leadingtoimpoverishmentandpoverty.ThispapertriestoinvestigatethetrendsandpatternsinOOPEinIndiafrom1994-2012byapplyingtheAndersen’sbehaviouralmodelofhealthcareutilization.

Methods: Data has been used from the three rounds of nationally representative consumerexpendituresurveys i.e.1993-94,2004–05and2011–12conductedbytheMinistryofstatisticsand planning implementation, Government of India.We employedmultiple generalized linearregressionmodeltoexploretherelativeeffectofvarioussocio-economiccovariatesonthelevelofOOPE.

Result:Resultsindicatethattherehasbeenaconsistentincreaseininpatient(4.53%),outpatient(1.2%)andtotalOOPE(1.4%)between1994-2012.Thegapbetweenricherandpoorersegmenthas further widened along with noticeable regional disparities across the Indian regions. Theshareofmedicines inover-allOOPEwashighest followedbyother components, though therehasbeendecline in thepercentage shareofOOPEonmedicines (83% to67%)between1994-2012. OOPE among the elderly, urban and richer segment of the population was higher ascomparedtotheircounterparts.

Conclusion: Our results highlight the need to explore the reasons underlying the lack ofeffectivenessofexistinghealthfinancingmechanismandhealthservicesinreachingtotheless-advantagedsectionofthepopulation.Specialattentionisrequiredtocaterthehealthfinancingneedsoftheelderly,ruralandpoorersegmentofthepopulationandreducingtheunjustburdenofhigherOOPEinIndia.ThereisneedtostrengthentheaffordabilityforhealthpaymentsamongIndianhouseholds.

Keywords:Universalhealthcoverage,OOPE,affordability,GLM,India.

The Global Financing Facility Investment Case - a PHC approach contributing to Madagascar’s UHC initiative.

EliseLang,EliRamamonjisoaandChristineOrtiz:HealthPolicyPlus,Palladium,

Background:Madagascar’s progress on health indicators has stagnated or declined in recentyears.Neonatalmortalityincreasedfrom24‰in2008to26‰in2013(DHSdata).Theprimaryhealthcare (PHC) system struggles with a low government budget allocation, lack of qualifiedmedical professionals, insufficient supply of drugs/consumables and weak data informationsystems. In 2017, the Global Financing Facility (GFF), a catalytic fundingmechanism, selected


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Madagascar as one of their third round of countries. TheMinistry of Public Health (MSANP)convened stakeholders to develop a reproductive, maternal, neonatal, child and adolescenthealthandnutritioninvestmentcase-aprioritizedplanforaddressingRMNCAH-Nchallengesinthe country to inform the use of the catalytic funding. In Madagascar, this plan supportsstrengtheningof thePHC systemand the recently launchednewgovernmenthealth financingmechanismandUHC.

Objectives: Maximize resources available for health, and mobilize domestic resources, byprioritizingspecificRMNCAH-Ninterventionsinlinewiththecountry’svisionforachievingUHC.

Methodology: HP+ supported the MSANP to convene a technical working group includinggovernment, donor, and civil society representatives. Participants used the EQUIST tool,mortalitydataandcoverageratesperregionandunitcoststoprioritizefeasible,highlyeffectiveand efficient interventions. Subsequently HP+ used the OneHealth Tool to budget choseninterventionsin12prioritizedregions.Thecostwillbecomparedtotheresultsfromaresourcemapping exercise to determine funding gaps and provide a base for determining roles andresponsibilitiesforimplementingtheinvestmentcase.

Findings:ThescenarioultimatelychosenforMadagascarfocusesonthePHClevelwithemphasisonstrengtheninghumanresourceavailability,particularlycommunityhealthworkers,andtheirperformanceusingperformance-basedfinancing.Theinvestmentcasefocusesonstrengtheninghigh-impact maternal, neonatal and nutrition interventions and increasing financial access toPHCbystrengtheningthenascentvoluntarycontributionhealthfinancingmechanismanduseofvouchers forvulnerablepopulations. Initial resultsshowthat17732644 people in12regionswillbenefitfromthisapproach.

Conclusions:Developinganinvestmentcaseallowsthegovernment,developmentpartners,civilsociety andprivate sector partners to align funding priorities for RMNCAH-N and improve theefficiency of limited resources available in Madagascar by targeting vulnerable regions andpopulationstoimprovethehealthofmothersandchildren.

Assessing the weakness of an existing diseases programme should be a good way for strengthening the health systems toward Universal Health Coverage: case of Mauritius.

DR.LaurentMUSANGO¹;Mr.PremduthBURHOO²;Dr.FaisalSHAIKH¹;DR.MaryamTIMOL³¹WorldHealthOrganisation,CountryOfficeofMauritius.²MauritiusHealthInstitute(MIH)³MinistryofHealthandQualityofLife(MOHQL)

IntroductionNon-Communicable diseases (NCDs) are the leading cause of death, disease anddisabilityinMauritius.ThefourmajorNCDs(cardiovasculardisease,cancer,chronicobstructivepulmonarydiseasesanddiabetes),accountfornearly81%ofalldeathsand85%ofthediseaseburden.TheWHORegionalOfficeforEuropeinitiatedathree-yearworkprogrammeonhealthsystems strengthening to accelerate improvements in NCD outcomes. As Mauritius shares asimilarepidemiologicalprofileasmanycountriesintheEurope,itwassuggestedtousethesametoolusedinEuropeforasimilarassessmentinMauritius.

MethodologyThecountryassessmentstartswithathoroughanalysisofthemainNCDoutcomeindicatorstogetherwithanoverviewofthetimetrendsnotedoverthepast15years.Ananalysisof fifteenhealthsystemfeaturesthatmayrepresentachallengeorpresentanopportunity forimproveddeliveryofcoreNCDinterventionsandserviceswerethencarriedout.Aparticipatoryandflexibleapproachwasusedforthisassessment;amultidisciplinaryteamwassetuptocarryout the assessment. Five Working Groups (WGs) of 5-6 members each were constituted to


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review the 15 health system features and two workshops were organized one to presentpreliminaryfindingsandconclusionstootherWGsandstakeholdersandanotheronetovalidatethereport.ThereportidentifiedkeysopportunitiesthatthecountrymaycontinuetobuildonaswellaschallengesandpossiblesolutionstoaddressthemthroughstrengtheninghealthsystemstowardUHCandservicesforNCDsoutcomes.

ResultsPoliticalcommitmenttostrengthenHealthsystemsforNCDsoutcomes,explicitpriority-settingapproaches, interagencycooperation, coordinationacrossproviders,effectivemodelofservice delivery with effective management, integration of evidence into practice, incentivesystems of human resources for health, and free healthcare services includingmedicines andlaboratoryteststouserswereidentifiedasopportunitiesthatneedtocontinuetobestrengthenandtobuildPHConthem.However,thefollowingchallengesthatneedtobemitigatewerealsoidentified:thepopulationwhich isnotadequatelyempoweredtochangebehavior, inefficiencyrolethatthePrimaryHealthCareinthecountryandweaknessesinthediagnosticandpreventiveservices,powerexplorationofdatageneratedbythehealthsystemandunavailabilityofmoderninformationsolutions.

ConclusionandrecommendationsBasedontheassessmentoffeaturesaswellasthechallengesidentifiedand thediscussionswith key stakeholders, policy recommendations suchas foster acultureof continuous improvementofqualityof careatall levels, restoreconfidence inpublichealthservicesandbalanceprivatesectordevelopment,reengineerhealthservicesorganisationtoputPHCatthecentreofUHC,empowercommunitiesforhealthierenvironmentandlifestylesand reach the unreached population especially the poor were suggested for improvement ofhealthsystemstowardUHC.TheroadmapfortheimplementationoftherecommendationswasalsoapprovedbytheMinistryofhealthandstakeholders.

Monitoring progress towards attainment of financial risk protection in Uganda

BrendanKwesiga1, TomAliti2, PamelaNabukhonzo3, SusanNajuko2, PeterByawaka3,Hsu Justine4GraceKabaniha5

WorldHealthOrganization,Uganda;MinistryofHealth,Kampala,Uganda;UgandaBureauof Statistics,Kampala, Uganda; World Health Organization, Geneva, Switzerland; World Health Organization,Brazzaville,Congo

Background: Monitoring progress towards attainment of Universal Health Coverage (UHC) isfocused assessing attainment of the goals on coverage of health services and protection ofhouseholdsfromtheimpactofdirectout-of-pocketpayments.AlthoughUgandahasexpressedaspirationsforattainingUHC,out-of-pocketpaymentsremainamajorcontributortototalhealthexpenditure. The aim of this study is to monitor progress on the financial risk protectiondimensionforhouseholdsinUganda.

Methods: This study uses data from the Uganda National Household Surveys for 2005/06.2009/10,2012/13and2016/17.Financial riskprotection ismeasuredusingcatastrophichealthpaymentsand impoverishment indicators.Healthpaymentsaredefinedas catastrophic if theyexceedasetthresholdofthebudgetshareoftotalhouseholdconsumptionexpenditurebasedonthresholdsof10%and25%.Healthpaymentsareimpoverishingiftheypushthehouseholdsbelow the poverty line (defined using the US$1.91/day and Uganda’s national poverty line).Logisticregressionmodelisusedtoassessfactorsassociatedwithhouseholdfinancialrisk.

Results: The results show that although progress has been made in reducing financial riskprotection,thisprogressremainsminimalandthereisstillariskofreversalofthistrend.Wefindthatalthoughcatastrophichealthpaymentsat10%thresholddecreasedfrom22.4%in2005/06


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to13.78%in2012/13,weobservean increaseto14.22%.ThepercentageofUgandanspushedbelow the poverty line (US$1.91/day) has also decreased from 5.2% in 2005/06 to 2.71% in2016/17.Weshowthatthedistributionofthisriskvariesacrosssocio-economicstatus,locationandresidence.Wealsoshowthatsomehouseholdcharacteristicsaremoreassociatedwiththehouseholdincurringfinancialrisk.

Conclusion: To address the burdenof financial risk protection, there is need for interventionsaimedatreducingout-of-pocketpaymentsespeciallyamongthosemostaffected.Inshortterm,ensuringthatthepopulationaccessespublicallyfinancedservicesthroughinsuringavailabilityofkeyinputsrequiredatthesefacilitiesiscritical.

Parallel Session 2-2 Equity in Health

Correlates of `Public Awareness of Patient Rights and Responsibilities in Healthcare Delivery in the Sagnarigu District, Ghana

GilbertAbotisemAbiiro,DepartmentofPlanning, FacultyofPlanningand LandManagement,UniversityforDevelopmentStudies,Wa,Co-authors:GilbertAbotisemAbiiro,RogerAyimbilaAtinga,BernardAfikAkanpabadaiAkanbang

Background: Severe human rights violations in health settings has led to the enactment ofvarious health-related human rights legislations, treaties, policies and charters to protect thebasicrightsofpatients.However,patientsstillfacevariouschallengesinaccessingtheserights,duetopoorawarenessofthespecificpatientrightsandresponsibilitiesenshrinedinthevariouspatientcharters.

Objectives: This study assessed public awareness of patients’ rights and responsibilities asenshrined in theGhanapatient charter and the factors that are associatedwith awareness ofpatients’rightsandresponsibilitiesintheSagnarigudistrictoftheNorthernRegionofGhana.

Methods:Thestudyemployedapurelyquantitativecross-sectionaldesign.Ahouseholdsurveywasadministeredto400residentsofthedistrict,selectedthroughmulti-stagerandomsampling.UsingSTATA12software,descriptivestatisticsonthe levelsofawarenessofeachpatientrightandeachpatientresponsibilityweregenerated.Seriesofbinarylogisticregressionmodelswerealsoruntodeterminethesocio-demographiccorrelatesofawarenessofeachpatientrightsandeachpatientresponsibility.

Key findings:Theresults revealeda rangeof35.5%-74.25% levelofawarenesson individualpatient rights and 46.5%-71.3% awareness on individual patient responsibilities. Per-urbanresidency,tertiaryeducation,goodself-relatedhealthstatusandhealth insurancemembershipwerestatisticallyassociatedwithsignificantly (p<0.05)higher levelsofawarenesson individualpatients’rightsandresponsibilities.Islamicreligionwasstatisticallyassociatedwithsignificantly(p<0.05)lowerlevelsofawareness.

Main conclusion: We conclude that public education on the existence of the Ghana patientcharter and the various patient rights and responsibilities enshrined in the charter, especiallywithinruralandMuslimdominatedcommunities,shouldbeintensified


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Including the Excluded: Stakeholders Strategies to Improve Access to Health For The Socially Excluded In Nigeria

Chinyere.C.OkekeDépartementdemédecinecommunautaire,UniversitéduNigeria,EnuguCampus.Benjamin.S.C.Uzochukwu,GhazalaMir.

Background Public sectors in any country has the responsibility of providing equal access andinclude all groups. Nigeria has numerous development-oriented public policies, but little hasbeenachievedintheareaofsocialinclusionwhichseekstoprovideaconduciveenvironmenttoall.

Social exclusion is one of the social determinants of health. Actions to alleviate this state areseenascrucialinaddressingthehealthneedsofall,andthehealthneedsofmarginalisedgroupsinparticular. It isclosely linkedwiththeethosof theUnitedNationsSustainableDevelopmentGoals which suggests that improving the health status of such socially excluded groups mayimprove thehealthof thepopulationasawhole.Thus several strategies to improveaccess tohealthhavebeendeveloped.

Aims and objectives of the research To identify strategies that exist and to highlight keyinfluencesonimplementationofstrategiestoimproveaccesstohealthforthesociallyexcluded.

Methods Co-production method was used.We conducted a systematic scoping review of 37published evidence selected from 257 identified abstracts. We also obtained feedback onstrategies from over 60 expert participants who took part in 3 national workshops. In-depthinterviewswithstructuredinterviewguideswereconductedonpolicymakersandimplementersandheadsofcivilsocietyactivistwhilefocusedgroupdiscussionwasconductedamongstgroupsat the rural areas and members of Internally Displaced People camps. Data was analysedmanuallyusingthemesfromthestudycontextualframework.

FindingsStrategies identifiedat themacro level include:"SavingOneMillionLivesProgrammefor Results" (SOML-PforR), conceived by the Federal Ministry of Health to save the lives ofmothersandchildrenby increasingaccessandutilisationofevidence-based,cost-effectiveandhighimpactmaternal,childandnutritioninterventionsinNigeria.FreeMCHprogramestablishedtoprovidefreehealthcareservicesforthepregnantwomenandchildrenunderfiveyears.

Meso level: Principles for “Bringing PHC under One Roof” and the establishment of HealthManagementCommittee.

Key influences on implementation of strategies include implementation challenges; corruptionand lackof accountabilityof public fundsmapped for variousprojects aswell as intricaciesofpolicymakingatthenationalAssembly.Multisectorialcollaborationopportunitiesexist.

Conclusion Social exclusion is underpinned by combination of different drivers, and in-depthunderstandingofeffectivestrategiesforsocialinclusionisrequired.Futurepoliciesandpracticesshouldtakeaccountofthereportedeffectivestrategiesandimproveonthem.

Assessing socioeconomic inequalities in maternal healthcare over time; evidence from four African countries

DoreenAnyamesemOdame,Dr.AmaPokuaFenny,Mr.DerekAsumanUniversityofGhana,Legon-InstituteofStatistical,SocialandEconomicResearch

AbstractThoughmostAfricancountriessawsomeimprovementsinmaternalhealthoutcomes,mostof thesecountriesdidnotmeet theMDG5 targetof190deathsper100,000 livebirths.Ensuringuniversalaccess tohealthcare isvery instrumental in improvinghealthoutcomes.To


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be able tomeet the SDG target of 70 deaths per 100,000 live births by 2030, theremust beequity and equality is access to and utilisation of maternal health care services. This can bepossiblebyeliminatingsocioeconomicdifferencesinaccesstomaternalhealthcare.Thispaperseekstodocumentthedegree,extentandevolutionofsocioeconomic inequalities inmaternalhealth outcomes in 5 African countries; Kenya, Ethiopia, Rwanda, Uganda and Tanzania. Thepaperexamines3maternalhealthoutcomes–timingoffirstantenatalvisit,numberofantenatalvisitanddeliverybyskilledattendant.Thepaperhas2mainobjectives;(i)estimatethedegreeandtrendofsocioeconomicrelatedinequalitiesinaccessanduseofmaternalhealthcareand(ii)asses the correlates of the socioeconomic related inequalities inmaternal health services andtheir contribution to the level of observed inequalities. The study adopted theWagstaff andErrygers measures to measure the bivariate rank indices. These indices do not explain thecontribution of socioeconomic characteristics in the observed differences. A generalisedregression decomposition technique is therefore adopted to assess the sources ofsocioeconomic inequalities in health. The paper uses different rounds of Demographic andHealthSurveys inthevariouscountries.Thesesurveysprovideextensive informationonaccessanduseofvariousmaternalhealthcareservicesfromnationallyrepresentativesampleofwomenofreproductiveages(15–49)

Horizontal inequity and inequality in healthcare utilisation in South Africa: A longitudinal analysis using the National Income Dynamic Survey (NIDS)

TanjaNalediGordon,HumanScienceResearchCouncil,PretoriaProfFrederikBooysen,SchoolofEconomicsandBusinessSciences,UniversityofWitwatersrand(Wits)ProfJosueMbonigaba,DepartmentofEconomics,UniversityofKwaZulu-Natal(UKZN)

Background:Thedistributionofhealthcarebasedonneedratherthansocioeconomicstatushasbecome an inherent object for health systems in both developed and developing countries.Sustainable Development Goal (SDG) three urges the achievement of equitable, quality,affordablehealthcarecoverageforall.Therefore,thispaperexaminesthedegreeofhorizontalinequityinhealthcareutilisationinSouthAfricaandthemajordriversofinequality.

Data: The National Income Dynamic Survey (NIDS) is the first of its kind in South Africa. Thebiennialstudyisanationallyrepresentativepanelsurveyintendedtotrackthesameindividualsovertime.Todatefourwavesareavailableinthepublicdomain.Thesurveyintendedtofollowtrends and patterns in health, economic, institutional and social characteristics of thepopulation.

Method: Concentration indices for absolute healthcare use and utilisation given need, whilecontrolling for non-need and socioeconomic factors were calculated to measure horizontalinequity (HI)usingaprobit regressionmodel. Inaddition, absolute concentration indicesweredecomposedtodeterminethemajorcontributorstoinequalityinhealthcareutilisation.

Findings: There was a significant increase in pro-rich horizontal inequity (HI = 0.064, p0.001)betweenwave1(2008)andwave4(2014)(HI=0.083,p0.001)forconsultationsinthepast12months. Distinct horizontal inequity patterns were found for private and public consultationsovertime.Horizontalinequitytotheadvantageofthewealthyforprivateconsultationsandthepoor for public consultations. From the decomposition analysis, non-need and socioeconomicfactors such as medical aid, wealth, education and employments were the major drivers ofinequality.

Conclusion: Sufficient evidence was found for the existence of horizontal inequity, increasingovertimeforoverallutilisationandpersistentforprivate/publicconsultations.Furthermore, inorder forSouthAfrica tokeep in linewith internationalpolicygoalsandobjectives,underlying


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influentialfactorssuchasthemechanismsofhealthcarefinancinghavetobeaddressedinordertonarrowthedegreeofhorizontalinequitywithinthehealthsystem.

Socioeconomic inequalities in the multiple dimensions of access: The case of South Africa

TanjaNalediGordon,HumanScienceResearchCouncil,PretoriaProfFrederikBooysen,SchoolofEconomicsandBusinessSciences,UniversityofWitwatersrand(Wits)ProfJosueMbonigaba,DepartmentofEconomics,UniversityofKwaZulu-Natal(UKZN)

Background:TheNationalDevelopmentPlan(NDP)strivesthatSouthAfrica,by2030,inpursuitofUniversalHealthCoverage(UHC)achieveasignificantshiftinequity,efficiencyandqualityofhealth services provision. This paper, with a view to informing this policy endeavour and theassociated achievement of the Sustainable Development Goals (SDGs), assesses the extent ofsocio-economic inequalities in health and healthcare across various dimensions of access tohealthcareusinganintegratedconceptualframework.

Data:The2012SouthAfricanNationalHealthandNutritionExaminationSurvey(SANHANES-1)collected data on a variety of questions related to health and healthcare utilisation andsatisfaction,withahouseholdmodulecollectinginformationonhousinginfrastructureandassetownership.

Method:Awealth indexwasconstructedusingMultipleCorrespondenceAnalysis (MCA)andarangeofconcentrationindiceswerecalculatedusingStata’sconindexcommand.

Findings:Intermsofhealthcareneeds,goodandillhealthareconcentratedinthenon-poor(CI+0.077, p0.001) and poor (CI -0.043, p0.001), respectively. The non-poor perceives a greaterdesireforcarethanthepoor(CI+0.064,p=0.013).However,unmetneedisconcentratedinthepoor(CI-0.031,p0.001).Thesocio-economicdivideintheutilisationofpublic(CI-0.241,p0.001)andprivate(CI+0.253,p0.001)healthcareservicesremainsstark.Thepoorarelesssatisfiedwithhealthcareservices(CI-0.042,p=0.026)andhealthcareprovision(CI-0.041,p=0.030).

Conclusion: The broader health system remains characterised by deep inequalities across thedifferent dimensions of access to healthcare. The poor are discriminated against across thecontinuum of access to healthcare. National Health Insurance (NHI), when implementedeffectively, promises to play an important role in bringing quality healthcare services to theeconomicallydisadvantaged.

Keywords:access,healthinequality,healthcare,concentrationindex,SouthAfrica

Leaving no one behind: Assessing socioeconomic inequalities in the pursuit of Universal Health Coverage in Ghana

JacobNovignon,KwameNkrumahUniversityofScienceandTechnology,Kumasi-Ghana

In the bid to achieve universal health coverage (UHC), Ghana rolled out the National HealthInsuranceScheme(NHIS).Thisisconsideredthelargesthealthfinancingreforminthehistoryofthecountry.TheprimaryobjectiveoftheschemeistoremovefinancialbarrierstohealthcareaccessinGhana.Whilevariousstudieshaveevaluatedtheimpactoftheschemeonhealthcareaccessandutilization,nostudyhasanalyzeditsroleinbridgingtheinequalitygapinhealthcareaccess.Wetestthishypothesisinthecurrentstudy.WesoughttofindoutiftheintroductionoftheNHIShashelpedreducesocioeconomicrelatedinequalitiesinhealthcareaccess.


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WeuseddatafromthreeroundsoftheGhanaDemographicandHealthSurveys(2003,2008and2014).Using threehealthcareutilizationmeasures -Antenatal care (ANC),Deliveryby trainedattendants(DTA)andcareforfeveramongchildrenunderfive-weanalyzeddatainthreesteps.Firstwe constructed concentration curves toexamine the trend in inequalitybefore andafter2004when the schemewas established. In the second step, concentration indices (CIs) werecomputed for each outcome variable across the years. Finally, the concentration indicesweredecomposedtoestimatetheimpactofNHISoninequalityinhealthcareaccess.

The concentration curves show thatutilizationofANC, fever careandDTAwere concentratedamongtheprivileged.However,thetrendsshowthe levelsof inequalityhasdeclinedaftertheintroductionoftheNHIS.TheCIsconfirmthiswithinequalityinANCserviceutilizationdecliningfrom0.302 in2003 to0.177 in2014.Similarly, inequality inDTAdeclined from0.597 to0.423over the sameperiod. The decomposition results show that access toNHISwas an importantcontributor to inequality inhealthcareaccess.For instance, in2014,access toNHISexplainedabout3.17%ofsocioeconomicrelatedinequalityinANCserviceutilization.Thiswasstatisticallysignificantat5%level.

The findings suggest that thepursuitofUHC inGhanahasbeenbeneficial for thepoor. Ithashelpedinbridgingthehealthcareaccessgapbetweentherichandthepoor.Thereis,therefore,theneed to scale-up theNHIS inGhana toachieve full universalhealth coverage. In countrieswheresuchschemesdonotexist,thereisneedtodirecteffortstoencourageitsestablishment.

Keywords:Healthinsurance,inequality,universalhealthcoverage,Ghana

Health inequality assessment: reproductive, maternal and child health in Uganda

Ms.GeraldineAgiraembabazi,MakerereUniversitySchoolofPublicHealth,Kampala,UgandaBackground:Healthinequalitiescontinuetopersistaroundtheworldingeneral,andparticularlyinlow-andmiddleincomecountries.Inequalitiesinhealthareevidentintheunequalwaythathealthservicesareaccessedbypeopleofdifferentincomelevels/economicstatus,gender,socialclasses and ethnic groups. They also manifest in variations in health outcomes according toeducationlevel,andinthetendencyforhealthsystemstobettermeettheneedsofpopulationsin certain geographical areas1. Now is especially a time to confront health inequalities sincesocialdeterminantsofhealthandprogresstowardsuniversalhealthcoveragehaveemergedasprioritiesforglobalhealth.Identifyingwhereinequalitiesexistandmonitoringhowtheychangeover time is essential to creating an equity-oriented health sector and provides a basis forincorporatingequityintoevidence-basedhealthplanning.

Objective: To assess health equity reproductive, maternal, newborn and child healthinterventionsbyanalyzingsurveydataforlevels,trendsanddisparities.

Methods:TwomostrecentavailabledatafromtheUgandaDemographicHealthsurveys(2006,2011) was analyzed looking at six coverage indicators and two equity stratifiers: wealth andregion.Inequalitieswereassessedwithtwosummaryindicesforabsoluteinequalityandtwoforrelativeinequality.

Results: By economic status, the least equitable interventions were coverage of skilled birthattendant and modern contraceptive use. In terms of absolute inequality, SBA is the leastequitable (diff: 44.7 vs 26.4; SII: 48% vs 31%) but in terms of relative inequality, Modern1 WHO 2013 Handbook on health inequality monitoring: with a special focus on low- and middle-income countries


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contraceptiveuse is the least equitable (ratio: 3.1 vs 2; CIX: 19%vs 13%). Themost equitablecoverageindicatorwasDPTvaccine.Byregion,attendanceof4+antenatalcarevisitswashighestinKampala,followedbyKaramojaandtheeasternregionhadthelowestcoverageinbothyears.Coverage increasedover timenationallyand thiswasprimarilydue togovernmentscaleupofcareby introductionofhealthsub-districtsandabolitionofuser feesatpublichealth facilities.Theinequalitiesinhealthhaveremainedlargelyunchangedovertimeduetoworseningpovertylevelsandincreasedfertilityespeciallyamongpoorestpopulations.

Conclusion:Healthinequalitymonitoringshouldbegivenmoreemphasisasanimportantpartofoverall health sector planning and ensure that data get used for effective action. The mostinequitableinterventionsshouldreceiveattentiontoensurethatallsocialgroupsarereached.

Parallel Session 2-3 Community based health insurance

A Review of Community-based Health Insurance Schemes (CBHIS): Lessons from Nigeria and Ghana

*IfeanyiNsofor,**NanlopOgbureke,**CharlesUsie*EpiAFRIC_ABUJANigeria,**ChristianAidBackground Poverty can predispose a household to health risks, which can further aggravatetheir socio-economicstatus throughdecreasedproductivityandhighout-of-pockethealthcare.Universal Health Coverage ensures people do not suffer catastrophic health expenditure byimprovingaccess,affordabilityandqualityofhealthcare.

Aims and Objectives The objective of the study was to explore perceptions, barriers andopportunitiesforestablishingaCBHIS.

Methods A qualitative study with in-depth interviews and Focus Group Discussions withstakeholders of both existing and proposed CBHIS including representatives of primary healthcentres,HMOs,NationalHealthInsuranceScheme(NHIS)atstateandnationallevel,communitymembers.

KeyFindingsTheroleofNHISinCBHISforNigeriaisoneofbotharegulatorandanimplementerwithsignificantgapsinbothroles.Thesegapswhichincludeuseoftax-fundedmodelswithco-payments,wasfoundtobean inefficientand impracticalwayof fundinghealthcare inNigeria.The situation is worsened by the fragmented federal structure and lack of delineation ofresponsibilities across the different tiers of government. Although there have been a fewsuccessfulschemes,fundingCBHISremainsachallengebecauseofthehighlevelofsubsidizationby government and donors. In depth community engagement with beneficiaries is critical forenrolment, so also is the size of the risk pool to the scheme’s success. A detailed benefitpackage,qualityofhealthcareprovided,administrative,monitoringandevaluationcostsandtherelationship of the scheme sponsor with HMOs are important to recruit and keep enrollees.Overall,politicalwillandtrustiscriticaltothesuccessofascheme.

Main Conclusions Strong government partnership is imperative for establishing CBHIS. This isespecially important considering the high odds that the primary point of service for mostschemeswillbeagovernmentownedandrunPHCfacility.Thegovernment’srolewilldifferbycommunity.

Gaining the trust of members is as essential as government support. The need for actuarial,healthanddemographicstudiescannotbeoverlooked.


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Can Community Based Saving Groups (CBSGs) usher in Community Health Insurance (CHI) in rural areas? A case study of three districts in Eastern Uganda.

MUTEBIALOYSIUS&Dr.ElisabethEkirapaKirachoMakerereUniversitySchoolofPublicHealthBackgroundAsavingsgroupisagroupyoucanformwithyourneighboursandfriendstosolvefinancialproblemsbysavingsmallsumsofmoneytogether.WhileformationofSavingsGroups(SGs) has been identified as one of the ways to help households and individuals save atcommunity level, savinggroupsdoprovideaccess to financial services inespecially ruralareaswith limitedoptionswhen it comes to saving forhealth careand investmentofmoney. It hasbeenobservedthatjoiningsavingsgroupscanchangethefinanciallivesespeciallyofwomenandtheir families by expanding their financial choices and opening up new social and economicopportunities.

MethodsThestudyusedcommunitydevelopmentofficersandvillagehealthteammemberstomobilise community members into joining or forming saving groups. While in these groupsmembersweretrainedtosaveforwealthcreationandhealth.Thehealthaccountwasseparatefromthegeneralsavingsofthegroupandwasonlyusedonhealthrelatedmattersofrespectivefamilies.

Results It was noted in the intervention arms that the number of saving groups more thandoubled from 431 to 915 between September 2013 and December 2016 due to successfulmobilizationandsensitisation.Itwasalsonotedthatsomeparisheswhichhardlyhadanysavinggroupatthebeginningofthestudybytheendof2016hadatleastasavinggroupineverylocalcouncil 1withmembership of not less than 15 people.Out of 915 saving groups, 22%had atleastamembersavingforMNHinthegroupwhilethereststillsavedasindividualsorfamilies.

Discussion The effort to start a health account in every saving grouphas shown very positiveresponsegiventhatithasonlylastedforoneyear.Withcontinuedsensitisationandsupervisionofsavinggroupsbycommunitydevelopmentofficers,thereisstronghopethatthiscanserveasaformofhealthinsuranceinruralareaswherethereisnoformaltypeofhealthinsurance.

ConclusionsThese findingsare testimonythat ruralcommunitiescanadaptsavinggroupsasaform of health insurance that does not require them to undergo all sort of bureaucracies ofpaperworkandtraveltoandfromtowns.Itcanbemanagedlocallywithlittlesupervision.Withmoretrainingofgroupleadersinmanagementandleadershipskills,thegroupscanmanagethesavingsverywell.

Assessment of the feasibility of community=based health insurance (CBHI) scheme for financial risk protection in three african countries: a systematic review

Ochoma, Ogbonnia Godfrey : Department of Health Administration &Management, Faculty of HealthSciencesandTechnology,CollegeofMedicine,EnuguCampus,UniversityofNigeria,Nsukka.

Background, Aim andObjective:Of all the risks facingpoorhouseholds,health riskspose thegreatest threat to their lives and livelihoods.Oneof theways that poor communitiesmanagehealth risks, in combination with publicly financed health care services, is community-basedhealthinsurancescheme(CBHI).HealthcarefinancingthroughCBHIisagrowingconceptinthesub-SaharanAfrica, and this study has the objective of assessing the effectiveness of three ofthese schemes to see if they improvedaccess tohealth careand reduced financialburden fortheir members in the case of illness and if they stabilized members incomes and helped topreserveassetswhentheyfallsick.


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Methods: To enable this systematic review, studies of primary datawith proven concerns formethodology and design were selected which included enrolment in the community-basedhealthinsuranceschemeandhowmuchtheyperformedinprovidingfinancialriskprotectiontomembersintimesofneedinAfrica.Dataidentification:Thefollowingdatabasesweresearched:Google Scholar, Pub-Med, and Embase/Medline. Selection criteria: The inclusion criteria forstudies for review include: 1) clear reasons for the establishment of the CBHI; 2) theeffectiveness of the programme as a financial risk protector in times of need among others.Extraction of Data for Analysis:Using a data extraction form adapted fromGreenhalgh et al(2005), the selected studies were summarized based on their study design, the researchquestions,andtheresearchcontextoncoverage,findingsandvalidityoftheirconclusions.Theelectronic search yielded 521 references. Papers merited their full scrutiny after theconsiderationof their titleandabstract.Of thearticles identifiedaspotentially relevant to theresearchquestions,41werereviewedwhichconsequentlyproduced3papersfromthecountriesofSenegal,RwandaandNigeriathatmetalltheinclusioncriteria.

Results: The results of the review were mixed. Results seem to confirm the researchers’hypothesis that community-financing through pre-payment and risk-sharing reduces financialbarriers tohealth care. The ‘‘upper income’’ strata tend toparticipatemore than the averagegroup, for inability toafford the required insurancepremium.Limitedcoverageofferedby theschemes constitutes a threat of catastrophic illness, which is enough to drive individuals andfamiliesintopoverty.Improvingontheacceptabilityofcommunity-basedhealthinsurance(CBHI)which expands enrolment and broader risk pools must be considerate factors to enableimplementationandsustainability.

Mutual health insurance and financing of health expenses among families in Gouro country in Ivory Coast

BaudelaireAngeBATE,Master'sstudent-healthoptioninSociologyUniversityofFélixHouphouetBoigny,AbidjanCôted’Ivoire

Background: Public health policies implemented in Ivory Coast for many years have failed toachieve the health-related Millennium Development Goals. At a time when the SustainableDevelopment Goals (SDOs) are beingmet, most of the population is still struggling to accesshealth care. Disparities in access to health care are still significant. Mutual health insurancecompanies, beyond their impact on improving the health system, are bringing abouttransformationsinhealthmanagementatthefamilylevel.AccordingtotheworkofDoumbouya(2008), the threeobstacles toaccess tohealthcare forpopulations (geographical, financialandsocio-cultural) are still persistent. Indeed, the high cost of access to modern health carecombinedwithhouseholdpovertyisamajorfactorinaccesstocare.

Objective:OurresearchanalysestheroleofmutualhealthinsuranceinpromotingsocialequityamongfamiliesintheWestCentralofIvoryCoastamongtheGouropeople.Thegeneralproblemofthisarticleisrelevanttotheanalysisofthefinancingofhealthexpenditureswithinfamilies.Ina context of insufficiency of resources, monetarization of access to care and women'sempowermenttotakechargeofhealthcare,mutualaretransformingandchallengingthesocialrolesassignedtoeachsex.

Method:Thisresearchadoptsaqualitativemethodologicalapproachthatcombinesinformationgathering, documentary review, life stories, direct observation and in-depth individualinterviews.

Outcome:The triangulationof theempirical corpus in the theoreticalperspectiveof thesocialconstruction of gender roles by Vidal (2008) reveals that the operationalization of mutual


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societiesinGourocountryhascontributedtoaredefinitionofgenderrolesinfamilyhealthcaremanagement.Withtheadventofmutualhealthinsurance,therolesinfamilyhealthpreviouslyassigned exclusively to Gouro women are changing and are now shared between men andwomenwithinthecouple.

Conclusion: Mutual health insurance companies are entering the private sphere andtransforminggenderrelationsaroundhealth,wheremenareincreasinglytakingaleadingroleinfamilyhealthcare.

Effect of Community-Based Health Insurance on Utilisation of Preventive Health Services in rural Uganda.

EmmanuelNshakiraRukundo 1,2*,EssaChanieMussa 1,NathanNshakira 3,NicolasGerber1 JoachimvonBraun11CenterforDevelopmentResearch(ZEF)UniversityofBonn.Genscherallee3,53117Bonn2InstituteforFoodandResourceEconomics,UniversityofBonn.Nussallee19,53115Bonn3KabaleUniversity,PoBox317Kabale,Uganda

Background: Community-based health insurance (CBHI) schemes have emerged as strongpathways touniversalhealthcoverage indevelopingcountries.The focusof theirexaminationhas emphasised their impact on financial protection and on the utilisation of curative healthservices. However, very little is known about their possible effect on utilisation of preventivehealthservicesandstrategiesandyetdevelopingcountriescontinuetocarryaburdenofeasilypreventableillnesses.

Methods: To understand if this effect exists, we carry out a cross sectional survey on 464householdsfromcommunitiesservedbyalargeCBHIschemeinruralsouth-westernUganda.Weapply inverse probability weighting of the propensity score to estimate quasi-experimentaleffects.

Findings:WefindthatforhouseholdparticipatinginCBHI,theprobabilitiesforusinglong-lastingmosquito nets, treating drinking water, vitamin A iron supplementation and child dewormingincreased by 27.8, 24.9, 20.7 and 28 percentage points respectively. Moreover, the averagetreatment effect on the treatedwas also significant for long lastingmosquito nets, vitamin Asupplementation, and iron supplementation and deworming. We postulate that this effect ispartlyduetoinformationdiffusionandsociallearningwithinCBHI-participatingburialgroups.

Conclusions: This work gives insight into the broader effects of CBHI in developing countries,beyond financialprotectionandutilisationofhospital-based services.Policymakers inUgandaandotherdeveloping countries should consider scalingup insuranceprogrammesnotonly forresourcemobilisation forhealthbutalsopossibleeffectson incentivisinguptakeofpreventivehealthservices.

Parallel Session 2-4 Drugs & Medicines

The effects of medicines availability and stock-outs on household’s utilization of health care services across six district councils in Dodoma region, Tanzania

EmmanuelNshakiraRukundo 1,2*,EssaChanieMussa 1,NathanNshakira 3,NicolasGerber1 JoachimvonBraun11CenterforDevelopmentResearch(ZEF)UniversityofBonn.Genscherallee3,53117Bonn


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2InstituteforFoodandResourceEconomics,UniversityofBonn.Nussallee19,53115Bonn3KabaleUniversity,PoBox317Kabale,Uganda

BackgroundAvailabilityofqualitymedicinesintheprovisionofhealthcareserviceisanintegralpart of universal health coverage (UHC). Countries have been undertaking various healthfinancing reforms among else to address shortage of medicines at points of health servicedelivery, includingscalingupofcommunityhealth insuranceandpublic-privatepartnershipstoimproveavailabilityandaccesstoqualitymedicinesandpharmaceuticalservicesinunderservedareas. This study assesses the effects of medicines availability and stock-outs on health careutilizationacrosssixdistrictcouncilsinDodomaregion,Tanzania.

MethodsA cross sectional studywas carried out across district councils of Dodoma region inMay2017, includingahouseholdsurveyandahealthcare facilitysurvey.Atotalof109publicprimary health facilities (11 health centres and 98 dispensaries) were surveyed and 1469households within the health facility catchment areas were interviewed. Household data wasmergedwithhealth facilities details using global positioning system (GPS) coordinatewith theaidofSTATAsoftwareversion13.0tocreateageo-dataset.Wegeneratedanindexformedicinesavailability as mean scores across eighteen tracer medicines for each health care facilitysurveyed.Descriptiveanalysisandmultivariate logistic regressionsmodelswereusedtoassesstheeffectsofmedicinesavailabilityandstock-outsonutilizationpatterns.

ResultsAvailabilityofmedicinesoverthreemonthsFebruary–April2017wasabove70%acrossdistricts for most of the medicines assessed with few like ferrous salt and folic acid whichavailability was below 55%. We found evidence suggesting positive association betweenhousehold health care utilization and medicine availability index. Regression analysis on thehealth care utilization showed the following positive associations: medicine availability index(odds ratio – OR, 2.818; 95% CI: 1.09-7.25; p < 0.05), households residing less than fivekilometresfromthehealthfacility(OR,1.594;95%CI:1.06-2.39;p<0.05),thosereceivinghealthcareeducation(OR,2.667;CI:1.39-5.10;p<0.05)andpatientsreportinglessthansixtyminuteswaitingtime(OR,1.703;95%CI:1.11-2.60;p<0.05).

Conclusion This study has shown that availability ofmost tracermedicines is relatively good,withfrequentstock-outsofafewmedicinesandvariationacross levelofcareaswellasacrossdistrict councils. This highlights the need to improvemedicine supplymanagement along thesupply chain from facility to national level. This includes quantification and timely ordering athealthfacilityandperformanceoftheMSDinfulfillingorders.

Keywords:medicinesavailability,healthcareutilization,Dodoma,Tanzania

Consumption and expenditure on anti-diabetic drugs from 2016 to 2017 by beneficiaries of a health insurance mutual in Ivory Coast

AgbayaOGA,KOUAMEJérôme,KOFFIKouamé,UniversityofFelixHouphouet-Boigny–AbidjanIntroductionAccordingtotheWorldBank,thereisaneedtoinvestinUniversalHealthCoveragein Africa wherematernal and childmortality remains high, as well as nutritional deficiencies,whilemanyhealthsystemscannotcopewithepidemicsandthegrowingloadofchronicdiseasessuchasdiabetes.TheobjectiveofthisstudywastodescribethedistributionoftheconsumptionofantidiabeticdrugsandtheexpensesassociatedwithitbytheGeneralMutualofOfficialsandAgentsoftheStateofIvoryCoast.

MethodologiesThisisaretrospectiveanalysisofpaymentdatafordiabetesdrugsbytheMutual.The study took in consideration members and beneficiaries who purchased at least one


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antidiabetic drug in 2016 or 2017whose pharmaceutical voucher was treated at theMutual.Consumption was expressed in defined daily doses (DDJ)/patient/quarter. Average monthlyexpenditureswereestimatedbasedonthepublicpricesofeachdrugsoldinprivatepharmaciesinIvoryCoast.ThedatawereacquiredfromExcelspreadsheetsandanalysedbyusingRstudiosoftware.

Results Antidiabeticdrugshavebeen found for 10038mutualists aged21 to86 yearswith anaverageageof 54.65±10.39 years. Therewas amalepredominancewith a sex ratioof 1.29.Overthestudyperiod,102,792linesofantidiabeticagentsweretreated,81.77%ofwhichwereoralantidiabeticagents.

Of these drugs, gliclazide was the most commonly used molecule, followed by glimepiride,metformin and insulin. Gliclazide consumption increased by 2.96% (from 171.38 to 176.46DDD/patient/quarter) with a peak (176.46 DDD/patient/quarter) in the third quarter of 2017.Consumptionofglimepiride,metforminandinsulindecreasedby20.38%(from154.63to124.12DDD/patient/quarter),7.18%(from117.09to108.01DDD/patient/quarter)and7.75%(136.58to126.77DDD/patient/quarter)respectively.

The averagemonthly expenses for these treatments varied only slightly over time. Theywerehigher for sitagliptin (34435 F/month), insulin (24985.0069 F/month) and vildagliptin(22058.2821F/month).

ConclusionTheconsumptionofantidiabeticdrugsinthiscrosssectorofbeneficiariesofamutualhealth insurance mutual for access to medicines appears to be close to the consumptionobservedincountrieswithextendedhealthinsurancesystems.

KeywordsDiabetesmellitus,druguse,defineddailydose,IvoryCoast

Assessing the Rational use of Medicines (RUM) in community pharmacies in Ghana

BrendaYayraOpong1,JusticeNonvignon2,MosesAikins2,GenevieveC.Aryeetey2

PharmacyCouncil,P.O.Box,AN10344,AccraNorthUniversityofGhana,CollegeofHealthSciences,SchoolofPublicHealth.P.O.BoxLG13,LegonGhana

Introduction:Rationaluseofmedicines(RUM)forallmedicalconditionsisanessentialelementinachievingqualityofhealthandmedicalcareforpatients.Yetmorethan50%ofallmedicinesworldwide are prescribed, dispensed or sold inappropriately. Ensuring the availability,affordabilityandrationaluseofqualitymedicinesisanissueofconcernindevelopingcountries.Irrationaldruguseaffectsqualityofhealthcareandhas implicationsonefficacyofmedicines.Community Pharmacies serve as a vital sourceof informationondruguse tomembers of thecommunityandshouldpromotethesafeuseofdrugs.

Objectives: The study sought to assess rational use of quality and accessible medicines incommunitypharmaciesintheLedzokuku-KroworMunicipalityinAccra.,usingtheWHOlevelIIfacilitycorebasedindicators.

Methods:Adescriptivecross-sectionaldesignemployingthequantitativemethodwasemployedtotakeprospectivedatafrom6communitypharmaciesand180clients.ThestudyadoptedtheWHOlevelIIfacilitycorebasedindicatorsformeasuringrationaluseofmedicinesmainlyaccesstomedicines,availabilityofmedicines,medicinepricing,affordabilityandpatientcare.Variousscoresweregeneratedforeachofthefivedomainsasstipulatedintheguidelines.

Results:Majority (53.3%)of thepatients forwhommedicineswere intendedforwere femaleswhilstthoseaged30-59yearswereinthemajority(46.7%).About98.8%ofclientstravelledtothecommunitypharmacyin<1hourandatacost0.42timesthedailywageofthelowestpaid


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salaried government worker. Availability of key essential medicines was high (92.2%) and noexpiredmedicinewasfoundinanyofthedispensaries.Thesemedicineswereconservedunderconditionsthatscored80%.TheMedianPriceRatio(MPR)ofallthesurveyedmedicinesrangedfrom 0.13 to 26.11 implying thatmedicineswere being sold at a range 0.13 times lower and26.11 times higher than the international reference price. Asmuch as 60.83% of prescriptionmedicineswereboughtwithoutprescriptions.Labellingofmedicinesinthemunicipalitywaslow-58.9%although88.2%of themhadadequateknowledgeonhowto take theirmedicines.Theaverage cost of medicines bought was 0.73 times the daily wage of the lowest paid salariedgovernmentworker.

Conclusion:Theleveloftherationaluseofmedicinesincommunitypharmacieswasfoundtobegood, although therewere somemajor suboptimalperformance regarding somepatient carepractices.

Key words: Rational use of medicines, community pharmacies, access, availability, medicineprice,affordability,patientcare

Training Anambra State primary health workers on medicine management and provision of management tools: steps towards health systems strengthening for delivering primary health care

Chinyere.C.OkekeHealthPolicyResearchGroup,DepartmentofPharmacologyandTherapeutics,CollegeofMedicine,UniversityofNigeriaEnugu-Campus,Enugu,Nigeria1. DepartmentofCommunityMedicine,CollegeofMedicine,UniversityofNigeriaEnugu-Campus,Enugu,Nigeria2.

Background Medicinesarekeydeterminantsofpopulationhealthandof society’s trust in thequality and viability of health systems. It’s availability is ameasureof theperformanceof thehealthfacilitiesandthisisfacilitatedbythepresenceofessentialstockmanagementtoolsattheprimaryhealthcare(PHC)levelwhichisthefirstportofcallformajorityofthepopulace.Mostofthe PHCs are located in the rural areas which have been neglected over the years despiteharboringagreaterpercentageoftheState’spopulation.

Medicine management is the set of practices aimed at ensuring the timely availability andappropriate use of safe, effective, qualitymedicines and related products and services in anyhealth-caresetting. It involves selection,quantification,procurement, storageanddistribution.It’s use requires proper prescribing, packaging, dispensing and counselling and these tasksrequirequalifiedhealthworkersorotherrelevantpersonnelwithappropriateskills.

Aims and Objectives This study aimed to assess the effect of training primary health careworkersandprovisionofmedicinestockmanagementtoolsforeffectivemedicinemanagementpracticesintheprimaryhealthcentersinAnambrastate.

Methods The study was undertaken in 132 PHCs in Anambra State, Southeast Nigeria. Theintervention included provision of medicine stock cards and training on essential medicinemanagement. Data was collected using an observational check list, a pretested questionnaireadministeredtohealthworkersin-chargeofthefacilitiesbeforetheinterventionand6monthsafter the intervention and in-depth interviews. Data was analysed using SPSS and manualcontentanalysis.

KeyFindingsSixmonthsafterintervention,ofthe132facilities,knowledgescoreimprovedfrom31(23.5%)to97(73.5%),whilepracticescoreimprovedfrom40(30.3%)to81(61.4%)andbothwere statistically significant (P=0.000..).Mean scoresand standarddeviationbeforeandafterfor knowledge (6.10±2.48 and 8.78±2.24) and practice (6.06±3.32 and 8.49±3.37) ofmedicinemanagementwasfoundtobestatisticallysignificanttoo.


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Reasonsforthecurrentpracticeswerefoundfromin-depthinterviewstobelackoftrainingandsupportivesupervisionandalso lackofregularsupplyandharmonizationofdrugstocktools intheState.

Conclusion The training led to reducedmedicine stock-outs, improved availability and use ofmedicine stock management tools and proper storage and prescription of medicines. It isthereforerecommendedthatsuchtrainingsandinterventionsshouldbescaledupinallthePHCstoensureavailabilityofqualitymedicinesinthePHCs.

Medicines Availability and Accessibility under Performance-Based Financing (PBF): Lessons from Three Nigeria State Health Investment Project (NSHIP) Implementing States

Muhammed Abubakar, Binta A. Ismail, Federal Capital Territory (FCT) –National Primary Health CareDevelopmentAgency(NPHCDA),Abuja

Introduction Medicines occupy strategic role in a health system. In economic perspective,medicines are derived demands: consumed for maintaining health, preventing ill-health,treating diseases and managing chronic complications that could lead to more suffering,morbidity and mortality. Hence, it is one of the indicators used to assess a health systemsefficiencyandeffectiveness.Assuch, timelyuseofmedicines is imperative inanygivenhealthcaredelivery systems.Thisexplains the rapid increase in theessentialmedicines list from204moleculeswhen itwas developed byWorldHealthOrganization (WHO) in 1977 to about 374moleculesasat2013.Evidenceshaveshownthatmedicinesavailabilityhaverevertedepidemicof ‘killer diseases’ (HIV/AIDS,Malaria, respiratory diseases, cardiovascular diseases, childhooddiseases,diarrheadiseases).Achievingessentialmedicinesrequirementcouldenhancecountry’schancesinreachingUniversalHealthCoverage(UHC).However,desirableprogresshasnotbeenmade in low and middle income countries (LMICs) including Nigeria despite of severalinterventionsandhencereachingUHCmaybecomewishfulthinking.Hence,thegovernmentofNigeriahascommencedthepilotofPerformance-BasedFinancing(PBF)undertheNigeriaStateHealthInvestmentProject(NSHIP)intheselectedthreeStatesandthishasintroducedmeasurestoensurecontinuousavailabilityofessentialmedicinesintheprojectimplementingStates.ThispaperthereforeassessestheeffectofPBFinensuringefficientessentialmedicinesmanagement(EMM).

Material and Methods The WHO’s equitable access to essential medicines framework wasadaptedandusedtoassessthemedicinesaccessinthePBFimplementingStatesinNigeria.Allthehealthfacilitiesinthepre-pilotLGAsaresampledfromthethreeprojectStates.Informationregardingdrug fundingunderPBF,drugexpiration, indigentpatients’ (vulnerableorpoorestofthe poor) drug consumption and tracer drugs list were collected for the assessment. Simpledescriptivestatistics(mean/average,percentage,graphicalrepresentations)wereusedfordataanalysis.

ResultsThestudyfoundthat:morethan95%ofthesampledPBFhealthfacilitieshaveefficientessential medicines management: tools, financing, autonomy and supervision; identified andconfirmed indigent patients have 100% access to allmedicines at zero cost; non-existence ofmedicines expiration and informed community. The study concluded that the PBF under theNSHIPhasmadesignificantimpactonessentialmedicinessubcomponentofthehealthsystemsover previous interventions such as drug revolving fund (DRF) scheme and this may triggerroadmap toUHC.Thestudy recommended thatPBFapproachshouldbeadopted foressentialmedicinesmanagementinNigeria.


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Panafrican Regulation of the Pharmaceutical Industry via the Medicines Agency

GuyNJAMBONG,SorbonneBusinessSchool-UniversityParis1

My topic is of societal importance, because on the one hand, research on transcontinentalpharmaceutical regulation is almost non-existent, on the other hand, to support thedevelopmentofI.P.attheAfricanscaleforthemanufacture/importationthenthedispensingofqualitydrugs,according tostandardscommonto theentirecontinent,goes in thedirectionofextendingthelifeexpectancyofAfricans.

I wish to analyze the advent of WADA, to understand the history of the construction of theEuropeanMedicinesAgency (EMA), theUnited StatesDrugAdministration (USFDA) and China(CFDA),andthenbenchmark.ThiswillallowmetodrawlessonsandproposerecommendationsfortheadvancementoftheconstructionoftheAMA,consideringtheeconomicandmanagerialtheories. Also, understanding the organizational and budgetary strategies, the philosophy andmodalityofregulationoftheagencies,couldreinforcemyvision.

Moreover,thisworkhastheambitiontoapproachthepreceptsofmarketregulationaccordingto a heterodox positioning as well as the theories of the Agency, according to a neo-institutionalist approach. But again, thisworkwill be in the Afro-optimistic and pan-Africanistlineage.

Iamalreadyaskingmanyquestions:a)thinkandformalizerecommendationsforthecreationofthisAMA,alreadyonthe launchingpad, is it too late?b) If this isnotthecase,could itbetheresultoftheintroductionofthisSAatthesocietallevel,ifmyrecommendationsweretakenintoaccount, before, during or after? (c) What is the strategy for WADA to prioritize the Africancontinentalfreetradeprocess?

Mysubjectinitsintegraldimensioningissofarthefollowing:"Whyandhow,atthepan-Africanscale, regulate I.P. andhow to establish anAfricanMedicinesAgency, after the signingof thecontinental free trade treaty, can it contribute to its autonomousdevelopment,perennial andcenteredpatient?»

Tothis,mycentralquestion ishowshouldtheAfricanMedicinesAgencybedifferent fromtheEMEAandtheUSFDAandhowshouldithaveadimensionofeconomicregulationandnotjustpharmaceutical?

Spatio-temporal variations in the use of antimalarial drugs in Côte d'Ivoire from 2016 to 2017

JérômeKOUAME,OGAAgbayaS,KOFFIKouamé,FélixHouphouët-BoignyUniversity-Abidjan

Background and Objective The incidence of malaria can vary, at different times of the year,undertheinfluenceofenvironmentalandclimaticfactors.Drugconsumptiondataareimportantresources for understanding seasonal variations in malaria endemicity. The objective of theanalysispresentedhere is todescribe the spatio-temporal variations in theuseofantimalarialdrugsinCôted'Ivoireandtoestimatetheexpendituresthathavebeenattachedtothem.

Methods This is a retrospective analysis of the data on the consumption and expenditure ofantimalarialdrugs,amongthemembersandbeneficiariesoftheMutualGeneralofStateofficialsandagentsofCôted'Ivoire(MUGEFCI).Thestudyincludedpeopleofallageswhohadtakenatleast one antimalarialmedicine reimbursed by themutual betweenApril 2016 andDecember2017. Consumptions were expressed in terms of the number of official packaging units of


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medicinesequivalent toeach ICD.Spatial variationswere related to thenumberof "boxes"ofdrugsusedineachofthe31regionsofthecountry.Averagemonthlyexpenditurewasestimatedfor each drug from public prices in private pharmacies. The data was acquired on ExcelspreadsheetsandanalyzedfromJulytoOctober2018usingtheRstudiosoftware.

ResultsThesampleconsistedof315420peopleaged0to87yearswithanaverageageof26.38±19.88years.51.39%ofthepopulationwasmale.

764867 "boxes" of antimalarial drugswere consumed over the study period. 74.18% of thesewereartemether-lumefantrine-baseddrugs.Thelargestconsumption(38.36%)wasrecordedinthedistrictofAbidjanforallmoleculesandovertime.

Consumptionhasincreasedgraduallysincethesecondquarterof2016,untilitreachedthepeakof13,767(18.04%)boxesinthelastquarterof2016.Itthendeclinedcontinuouslyduring2017,sothatConsumptiontrendsofthepreviousyearhavenotbeenreplicated.

The averagemonthly expenditure ranged from 1751 FCFA (for artesunate) to 5503F CFA (forartemether).Theyhavechangedlittleovertime.

Conclusion The consumption of antimalarials has varied with regard to the population ofbeneficiaries,accesstocare,andactionstocontrolexpensesbytheMutual.

Keywords:Malaria;Useprofileofantimalarials;Volume/price;Mutualhealth;IvoryCoast

What are the potential health gains and policy implications of the World Health Organization recommendation on population-wide salt reduction by 2025?

Leopold N. Aminde, M.D. Faculty of Medicine, School of Public Health, The University of Queensland,Australia&ClinicalResearchEducation,Networking&Consultancy(CRENC),Cameroon.Co-authors:LindaCobiac,J.LennertVeerman Background: Premature mortality from cardiovascular disease (CVD) is greatest in the low-income and middle-income countries. To address this growing CVD and non-communicabledisease burden, the World Health Organization (WHO) recommended among others a 30%relative reduction in salt consumption as a population preventive strategy to reduce bloodpressureandCVDforcountries.Todate,thereislimitedevidencefromAfricaontheimpactofthispolicystrategy.

Aim: To estimate the potential impact on population health if Cameroon achieved this saltreductionrecommendationbytheyear2025.

Methods:With2016asbaseyear,anddatafromtheGlobalBurdenofDisease2016study,weuse a proportional multi-state lifetable model to estimate changes in burden of CVD inCameroonover10years(from2016to2025)ifpopulationsreducetheirsaltintake.Uncertaintyinourestimateswasassessedusingprobabilisticsensitivityanalysis.

Results:Ifthissaltreductionstrategyisachieved,ourmodellingpredictsthatby2025,therewillbe 15,500 (95%UI: 14,000 – 17,000) fewer incident cases of ischemic heart disease (7.3%reduction), 5,000 (95%UI: 4,500 – 6,000) fewer new cases of haemorrhagic stroke (9.4%reduction), 6,000 (95%UI: 5,800 – 6,200) fewer incident cases of hypertensive heart disease(16.9% reduction). Mortality will reduce by 3,400 (95%UI: 3,000 – 3,800) for ischemic heartdisease(6.4%reduction),3,100(95%UI:2,700–3,500)forhaemorrhagicstroke(9.5%reduction),and 950 (95% UI: 900 – 1,100) for hypertensive heart disease (15.7% reduction). In addition,29,000(95%UI:27,000–32,000)health-adjustedlifeyears(HALYs)wouldbegained.Probability


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ofprematuremortalityfromCVDissimilarlypredictedtodecreasewhilelifeexpectancywouldincreaseforbothmenandwomen.

Conclusions: Substantial health gains could be made if populations reduced their saltconsumption in line with WHO recommendations. This would translate to reduction incatastrophichealthexpenditureandreducedhealthcarecosts.Thesefindingsareveryusefulforhealth policymakers in Cameroon and Africa as theywork towards initiating universal healthcareprogramsandcontemplateoncost-effectivemeasuresforprimarypreventionofCVD.

Parallel Session 2-5 Economics of Immunization, malaria, TB and HIV-AIDS

Mathematical modeling of drug inventory for sustainable pharmacy management in Uganda

PaulKizito*,SenfukaChristopher**,MaureenNSsempijja****KyambogoKampala,*KabaaleUniversity,***KyambogoUniversity

In today’s fast-paced and competitivemarket place, pharmacies need every edge available tothemtoensuresuccessinplanningandmanaginginventoryofdrugsunderdemanduncertainty.InUganda, the capacity to sustain cost-effective inventory of drugs in community pharmaciesneeds special attention. The paper intends to establish an optimal drug inventory model forsustainable pharmaceutical services in Uganda. The objective of this paper is to determineoptimalreplenishmentpoliciesofdrugssothatcustomerrequirementsaremetatleastcost.Aninventorymodelisthereforeproposedthatoptimizesreplenishmentpoliciesofaperiodicreviewinventorysystemofdrugsunderstochasticdemand;withparticularfocusondrugsformalariainUgandacommunitypharmacies.Weexplainafinitestatemarkovdecisionprocessmodelwherestatesofamarkovchainrepresentpossiblestatesofdemandfordrugs.Thepaperelaboratesonthe total replenishment, holding and shortage inventory cost matrix that is generated;representing the sustainability of performance for themarkov decision process problem. Thepaper examines two critical replenishment policies that are relevant to the drug inventoryproblem for sustainable pharmacymanagement: (1) replenishing additional units of drugs forinventory versus (2) not replenishing additional units of drugs for inventory. Using dynamicprogramming, the optimal drug replenishment policies are determined over a finite periodplanninghorizon.Preliminaryresultsindicatetheexistenceofanoptimalstate-dependentdrugreplenishmentpolicyandtheassociatedinventorycostsincurredbythepharmacychoseninthecase study. As a strategy for optimizing inventory of drugs for sustainable pharmacymanagement under demand uncertainty, computational efforts of using markov decisionprocesses show promising results. The stochastic inventory model proposed can improvepharmaceutical services through timely delivery of drugs in order to support sustainablepharmacymanagementinUganda.

Dossier d’investissement pour l’accélération du programme de vaccination plus au Bénin (2018-2023)

BakeuGonhokoJean-Macaire


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ObjectivesThemainobjectiveofthisstudyistodevelopaninvestmentplantoprovideadvocacyarguments formobilizing additional funding to accelerate thewider immunization program inBenin.

Specific objectives The specific objectives revolve around the following points: Estimate theadditional costs and impacts for accelerating the routine EPI; Develop realistic scenarios toacceleratethevaccinationprogrammore;

Methods The development of the investment case was facilitated by the use of the EQUISTplatform and the OneHealth tool (OHT). Equist is a tool for identifying disadvantagedpopulations,why they are disadvantaged, bottleneck analysis andwhat combinations of high-impact, evidence-based interventions and health systems strengthening strategies wouldproduce the best results .While theOHTmakes it possible to determine the budget and theimpactsintermsoflivessavedbyantigenandbyintervention.

Three scenarios based on composite indicators were adopted. In order to take into accountequity,allowingtheprioritizationof regions,severalcriteriasuchasvaccinationcoveragerate,mortality rate (severity) and number of deceased children (size) were defined and made itpossibletoselectpriorityregionsfollowing3polesformodeling.

• Thescenario1iscomposedoftheregionsofAlibori,Couffo,OuéméandPlateau.• Scenario 2 includes the regions of pole 1 plus the Atlantic, Borgou, Collines and Zou

regions.• Scenario3takesintoaccountallregions.

Findings The investment strategy proposed in this document for advocacy in mobilizingadditionalresourcesforvaccinationmoreinBenincouldsave1838childrenby2023forallthreescenarios. And considering a goal of 90% coverage by 2023 for penta3, the number ofunvaccinatedchildrenwouldbereducedfrom113,597unvaccinatedchildreninpenta3in2018to51,105unvaccinatedchildrenin2023atthenationallevel.AndtheadditionalcostsrequiredtoachievetheseresultsareestimatedatanaverageofUS$3.65percapita,orCFAF2005percapita.

ConclusionTheInvestmentcase isanadvocacytoolthatcombinesequitywiththebudgetandimpactofinterventions.Itleveragesadditionalresourcesforstrengtheninghealthsystems.

ConclusionTheInvestmentcase isanadvocacytoolthatcombinesequitywiththebudgetandimpactofinterventions.Itleveragesadditionalresourcesforstrengtheninghealthsystems.

Impact and cost effectiveness of rotavirus vaccination in 73 Gavi countries

ClintPecenka,PATHSeattle

BackgroundandaimsImmunizationhasbeenacornerstoneofcost-effectivereductionsinchildmortality and PHC is an essential tool to continue health progress globally. Previous cost-effectiveness analyses of rotavirus vaccination have found rotavirus vaccination to be highlycost-effectiveinlow-andmiddle-incomecountriesaroundtheworldandespeciallyacrossAfrica.Since the lastcost-effectivenessestimatesof rotavirusvaccinationacrossGavi countries, therehavebeenmanychangesinglobaltrendsandnewevidenceisnowavailable.Rotavirusmortalityhas decreased from 528,000 to 215,000 deaths worldwide, countries have experiencedeconomicgrowth,additionalcountrieshaveadoptedrotavirusvaccines,rotavirusvaccinepriceshave decreased, and new products are entering the market. The purpose of this study is toreevaluatetheimpactandcost-effectivenessofrotavirusvaccinationacrossGavicountries,andAfricainparticular,inlightofthesechangesandthepushtowardUHC.


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MethodsThisanalysisestimatesthecostsandbenefitsofrotavirusvaccinationprojectedacross10birthcohortsfrom2018to2027in73GavicountriesusingtherecentlydevelopedPROVAC’sUNIVACmodel.We track benefits and cost of vaccination for these cohorts over the first fiveyearsof life.During theperiodofanalysis, individualsmayormaynotget rotavirusdisease. Iftheygetrotavirusdisease,itcanbenon-severeorsevere.Non-severediseaseresultsinrecoverywith or without outpatient care. Severe disease results in recovery or death with or withoutoutpatient or inpatient care. We also account for potential intussusception cases linked torotavirusvaccination.

Results The analysis estimates the number of rotavirus gastroenteritis cases, outpatient visits,hospitalizations, and deaths averted by the vaccine. Analysis outputs also include economicbenefits expressed in termsof cost of care averted. Total cost of vaccinationprograms is alsocalculated. Cost-effectiveness results use the discounted incremental cost-effectiveness ratio(ICER)expressedinUS$perDisabilityAdjustedLifeYears(DALYs)avertedfromthegovernmentandsocietalperspectives.ResultsareexpressedforallcountriesaswellasperWHORegion.

Conclusions Rotavirus vaccination remains highly cost-effective across Gavi countries thoughmanyoftheimportantglobaltrendscontributetohighercost-effectivenessratios.Thisfindingisparticularly relevant for countries, includingmany in Africa, facing increased budget pressureduetodeclininginternationalsupportandadesiretoachievecost-effectivePHC.

Impact and cost-effectiveness of RSV maternal immunization in Gavi countries

RanjuBaral,ClintPecenka* Background and aims Childhood immunization has been a cornerstone of cost-effectivereductions in childmortality globally. As childhoodmortality falls, a larger share of the globaldisease burden is centered among young infants and women. These trends have heightenedinterestinnewinterventionstoaddressthisburden,includingmaternalimmunization.Maternalvaccinestoprotectyounginfantsfromrespiratorysyncytialvirus(RSV)areinadvancedstagesofdevelopmentandmaybeavailableasearlyas2023.Gavi,theVaccineAllianceisalsoconsideringRSV vaccines as part of the 2018 Vaccine Investment Strategy. RSV is estimated to result inapproximately 120,000 deaths annually,mostly among young infants in low-resource settings.The purpose of this study is to evaluate the impact and cost-effectiveness of RSV maternalimmunizationacrossGavicountriesandafocusonAfrica.

MethodsThisanalysisestimatesthecostsandbenefitsofRSVmaternalimmunizationin73Gavicountries using a static population-based cohort model.We examine costs and impacts from2023to2035 incomparison tono intervention, fromgovernmentperspective.Diseaseburdeninputs as well as cost inputs were primarily derived from recently published comprehensivesystematicreviews.Costsareexpressedin2016US$.BothcostsandDALYsareundiscounted.

ResultsUnder baseline assumptions across Gavi countries, RSVmaternal immunization avertsnearly15millioncases,3millionhospitalizations,and150,000deaths.Atavaccinecostof$2perdose, the average annual cost of vaccination program across all countries for the duration ofanalysiswasestimatedtobeabout$211million.Theeconomicvalueofcareavertedwasabout$10 million. The incremental cost-effectiveness ratio (ICER) per Disability Adjusted Life Years(DALYs) is estimated to be $185. Results are discussed for all countries aswell as the AfricanRegion.

Conclusions RSV maternal immunization is projected to be an impactful and cost-effectiveintervention inGavi countriesand theAfricanRegion.As the infantvaccineschedulebecomes


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increasinglycrowdedanddiseaseburdenshiftstowardneonates,maternalimmunizationofferstheopportunitytoprotectyounginfantsfromdiseaseandmayalsoenhancematernalhealth.

Parallel Session 2-6 Economic evaluation of health programmes

Cross-country comparison of the costs of healthcare services, and the cost drivers, at cross-border locations in Kenya, Rwanda, Uganda and Tanzania

AgnesGatome,NairobiAbtAssociates

Background: Private sources of expenditure constitute 20 to 49 percent of total healthexpenditure among East African Community (EAC) partner states (Burundi, Kenya, Rwanda,TanzaniaandUganda).Out-of-pocketexpendituresmakeupbetween68-95percentofprivatespending,exposinghouseholdstocatastrophicexpendituresandimpoverishment.Withvaryinglevels of insurance coverage (from 2% in Uganda to 95% in Rwanda), EAC Health MinistersrecognizedtheneedtoenhanceSocialHealthProtectionSystemsthatreducefinancialbarriersto healthcare. The aim of this study was to gather objective, cross-country, comparablehealthcarecostdatatoinformthedevelopmentofsustainablehealthcarefinancingsystemsfortheEACregion.

Methods: The USAID-funded Cross-Border Health Integrated Partnerships Project collectedfinancial and activity data from July 2014-June 2015 at 45 public and private clinics, healthcentres and hospitals within five kilometers of five cross-border locations in Kenya, Rwanda,Uganda and Tanzania. The excel-basedManagement Accounting System for Hospitals (MASH)was used to analyze the data from a provider perspective and generate average costs peroutpatient visit and per inpatient bed day at 42 health facilities. MASH uses a top-downapproach toallocateall facility costs tooutpatientand inpatientdepartments.Outpatientvisitand inpatientbeddayunitcostsarethenderivedbydividingthetotaldepartmentcostbythenumberofservicesprovidedinthetimeperiod.

Results:Resultsarepresentedbycountry,ownershipandlevel(clinic,healthcentre,hospital)forthecostperoutpatientvisitandinpatientbedday.Unitcostsvariedwidelybetweencountries.OutpatientvisitunitcostswereUS$1.54-14.19(Kenya),US$3.09-4.11(Rwanda),US$0.69-11.05(Uganda), and US$3.38-13.56 (Tanzania). Inpatient bed day unit costs were US$20.37-49.00(Kenya), US$14.64-17.24 (Rwanda), US$4.97-20.38 (Uganda). Costs were higher at privatefacilities compared to public facilities, and at hospitals compared to smaller clinics and healthcentres. Labor was the major cost driver in Kenya and Tanzania while drugs and suppliescontributed the most to unit costs in Rwanda and Uganda. The contribution of drugs andsupplies to overall costs was greater at hospitals compared to health centres and clinics,reflecting the increasedcomplexityofservicesofferedathigher level facilities. Inall countries,workloadwas 3-5 times higher at public facilities compared to private facilities, with clinicianratios as high as 1:15,000 outpatient visits in public facilities compared to 1:4,000 in privatefacilities.

Conclusions: Implementingsocialprotectionsystems intheEACwill requiredomesticresourcemobilization fromboth public andprivate sources andwell-structured systems to support thehealthcare financing functionsof collection,pooling, andpurchasing. The resultsof this study


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cansupportpurchasingdecisionsbygivinginsightintothecostofprovidinghealthcareservices,andthecostdriversacrosscountriesanddifferentlevelsoffacilities.Inaddition,thefindingscaninform the design of provider payment systems that account for differences in costs acrosscountries, ownership and levels and ensure sustainable provider reimbursement. Finally, theresultscanaugmentdiscussionsonworkload,staffingnorms,andtechnicalefficiencyoffacilitiesacrosstheEACregion.

Examining the economic impact of Type 2 Diabetes and the risk of catastrophic expenditure among a defined patient population attending a tertiary healthcare facility in Nigeria: Implications for Universal Health Coverage

*CharlesEzenduka,**ChisomC.Nwankwo*EnuguUniversityofNigeria,EnuguCampus,**NnamdiAzikiweUniversityAwka,NigeriaBackground/Objective: Little is known about the economic burden of diabetes and thecatastrophichealthimplicationsamongpatientswithT2DMinNigeria.Thestudyevaluatedtheeconomic burden of T2DM including complications and co-morbidities and the risk ofcatastrophichealthexpendituresinadefinedpatientpopulation.

Methods: A prevalence-based cost-of-illness study design was adopted to evaluate the directand indirect costs of managing T2DM patients in a university teaching hospital setting. Datacollection was based on non-interventional retrospective analysis of patient level data frommedical records of diabetic patients as well as face-to-face interviews using semi-structuredquestionnaires. Bottom-up costing approach informed the identification and estimationof thetotalandaveragedirectandindirectcostsoftreatment.Indirectcostsestimatewasonthebasisof human capital approach. Catastrophic cost wasmeasured from the non-food consumptionexpenditure of the respondents (income)while socioeconomic status groupwasmeasured bynumberof household itemsownedby respondents.Datawere collectedover aperiodof oneyearbetweenSeptember2016andAugust2017.

Results: Up to 359 diabetic outpatients were included in the study. The mean total cost(economic burden) of the disease per patient was N384,948.83 (US$1,099.85) per annum,comprising86%(US$948.60)directand14%(US$151.30)indirectcosts,atamonthlyaverageofUS$91.61perdiabeticoutpatient(atthe2017pricesapprox.N350=US$1).Greatestproportionof the cost, 17% was spent onmedications, followed by laboratory investigations (13%). Thecosts/burden increased with co-morbidities, complications, length of disease. Majority ofpatients (93%) reliedonOOPexpenditures to finance treatmentwithonly6%whoarefederalemployee enrollees paid through insurance. Of the OOP patients, 9% paid through sales ofproperties,whileon thewholeup to65%of thepatients subjected to the riskof catastrophichealthexpenditureat40%threshold,withthepoorestquartilemostlyaffectedatover51%.

Conclusion:FindingssuggestthatdiabetesimposessubstantialeconomicburdenontheNigerianpopulation subjecting a significant proportion of the low income individuals and families tocatastrophichealthexpendituresandfinancialimpoverishments.Projectedincreasingincidencesof diabetes, rising costs of care and absence of financial risk protection portends decreasingaccess to carewith implications to achieving the goals of theUHC. There is need for financialprotectionmechanismfordiabetespatientsforenhancedaccesstocareandreducedeconomicburden

Using Social Return on Investment (SROI) Methodology to Assess Value-for-Money of Public Health Interventions in Africa: An Example of an Evaluative SROI of Emergency Obstetric Care Training in Kenya

AduragbemiBanke-Thomas1,2*


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1DepartmentofHealthPolicy,LondonSchoolofEconomicsandPoliticalScience,London,WC2A2AE,UK2CentreforMaternalandNewbornHealth,LiverpoolSchoolofTropicalMedicine,Liverpool,L35QA,UK

Background Globally, there has been increasing interest to demonstrate value-for-money ofinterventionsusingvariousapproaches includingsocial returnon investment (SROI),which isaformofsocialcost-benefitanalysis.EmOCtraininghasbeenakeystrategyforreducingmaternalandnewbornmorbidityandmortality.Althoughgenerallyconsideredeffective,thereisminimalevidenceonthebroadersocialimpactand/orvalue-for-money(VfM).

Aimof the researchThisstudyassessedthesocial impactandVfMofEmOCtraining inKenyausingtheSROImethodology.

Methods Mixed-methods, including interviews and focus group discussions, quantitativestakeholder surveys, programmatic secondary data analysis and literature review wereconductedtoobtainallrelevantdata.FindingswereincorporatedintotheimpactmapandusedtoestimatetheSROIratio.Sensitivityanalysesweredonetotestassumptions.

Key findings Trained healthcare providers, women who received care from them and theirbabieswere identifiedasprimarybeneficiaries.EmOCtraining ledto improvedknowledgeandskills and improved attitudes to patients. However, increased workload was reported as anegative outcome by some healthcare providers. Women who received care expected andexperienced positive outcomes including reduced maternal and newborn morbidity andmortality.Afteraccountingforexternalinfluences,thetotalsocialimpactfor93five-dayEmOCtrainingworkshopsoveraone-yearperiodwasvaluedatI$9.5million,withwomenbenefittingthemostfromtheintervention(73%).TotalfinancialvaluationofinputswasI$745,000for2,965healthcareproviderstrained.ThecostpertrainedhealthcareproviderperdaywasI$50.23andSROI ratio was 12.74:1. Based on multiple one-way sensitivity analyses, EmOC trainingguaranteedVfMinallscenariosexceptwhentrainerswerepaidconsultancyfeesandthe leastamountoftrainingoutcomesoccurred.

MainconclusionsThisstudypioneeredtheapplicationofSROIinmaternalandnewbornhealthin Africa. Though there are still methodological improvements required for SROI before itsapplicationcanbescaledupinsettingslikeKenya,usingSROIprovidedcriticaladditionalinsightonVfMof EmOC training.As shown in this study, EmOC trainingworkshops are aworthwhileinvestment. The implementation approach influences howmuch VfM is achieved. The use ofvolunteer facilitators, particularly thosewhowork locally, todeliver EmOC training is a criticaldriverinincreasingsocialimpactandachievingVfMforinvestmentsmade.

Economic Evaluation of a community delivered project for leprosy case detection in Northern Nigeria

CharlesEzenduka,UniversityofNigeria,EnuguCampus

Background:Highcostofdetection inthedecliningphaseof leprosyendemicityanddwindlingfundinghasbecomeamajorconcernineffortsatcontainingandeliminatingthediseasewhichhascontinuedtospread.Evidenced-basedinformationontheefficiencyofstrategiesinleprosycasedetectionisneededtoconvincedonorsforcontinuedfundingsupportfortheprogramme.

Objectives: This study evaluated the cost-effectiveness of an innovative community deliveredlegacy project designed to improve leprosy case detection in northern Nigeria, utilizingvolunteersfromselectedcommunities.

Methods: Data was collected from 18 LGAs of the three states where the project wasimplemented tocompare thecostsandoutcomeof the innovativeprojectwith routinehealth


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systemmethodorusualcareinleprosycasedetectionandcontrol.PrimaryandsecondarydatawerecollectedfromtheprojectandroutinepracticerecordsandtheNTBLCP2015-2016annualreports. All costs and effects were measured from both providers’ as well as patients’perspectives. Effectiveness of the study was measured as the number of new leprosy casesdetected and outcome expressed as cost per case detected, as improvement in leprosy casedetection.Cost-effectivenesswascalculatedastheincrementalcostpercasedetected.AllcostswereconvertedtotheUSDollar (US$)at the2018exchangerateofN350to$1.00.UnivariatesensitivityanalysiswascarriedouttoevaluateuncertaintiesaroundtheICER

Results:Overall,theprojectdetectedatotalof373newleprosycasesatatotalannualcostofN17,268,016($49,337,19),averagingN46,295($132.27)pernewcasedetected.Keycostdriversincluderoutinemeetingexpenseswhichaccountedforthehighestproportion(28%)ofthetotalexpenditure.Socialmobilizationandtraining/workshopexpenses followedat17%respectively.Compared to routine practice , the legacy project generated ICER of N-4,917.48 ($-14.05) peradditionalnewcasedetected, indicatingadominanceovertheroutinecarebydetectingmorecasesatevenlowercost,asaveryefficientalternativemethod.

Conclusion:Evidenceindicatesthatthelegacyproject isaveryefficientandindeedcostsavingstrategyinleprosycasedetection.Itwillsurelyboostleprosycasefindingwhencomplementedwith routine practice and greater when combinedwith related community based health careservicessuchastuberculosiscontrolformorecostsavingsandgreaterefficiency.

Parallel Session 2-7 Aid and International health financing

Political Economy of Development Aid for Health in Post-GDP Rebased Nigeria: implications for financing universal health coverage

FélixObi,UniversitéduNigéria,Campusd’Enugu

Background: Nigeria transitioned into a low medium income country after rebasing its GDPrebasingin2014.Theeconomicgrowthhasbeenattheexpenseofinclusivegrowthwithabout70%ofthepopulationlivingunderthepovertywithoutaccesstosocialservicesincludinghealth.Againstthebackdropofcontractingrevenuebaseduetolowoilprice,ithasbecomeimperativefor the country to find ways to derive efficiency and value from existing sources such asdevelopment aid for health (DAH), while it explores innovative mechanisms for raising fundsdomesticallytoextenduniversalhealthcoveragetothecitizensintheSDGsera.

Methods:Usingqualitativeresearchapproach,thestudyexploredthepoliticaleconomyofDAHinNigeriawithin the contextof ongoinghealth financing reforms. Primarydata collectionwasthrough in-depth interviews (IDI) of purposefully-selected key health system actors, andcomplimented by review of published and grey literature including policy and programdocuments.Datawasanalyzedusingthematicandcontentanalyticalframeworks.

Results:Nigeria reliesheavilyonDAH to fund criticalpopulation-based interventions includinghealth systems strengthening initiatives. Aside multilateral and bilateral donors from OECDcountries, China and South countries have become key players, in addition to indigenous andinternational foundations. The main aid instruments include project support and technicalassistancewhicharechanneledmainlythroughgrantsandconcessionalloans/creditwithlittleornobudget-support.Donorfundsarerarelypooledintoabasketfundandrarelyusethecountry’s


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systems as transparency and accountability are major issues. Poor coordination by thegovernmentleadstoduplicationofeffortsandpooralignmentwiththecountry’spriorities.DAHprojects are inequitably distributed with some states left as orphan states. There was noconsensus on the efficiency of donor aid but services provided through donor funding wereperceivedtobeofgoodqualityduetouseofstandardproceduresandadequatesupervisionandqualityimprovementmechanisms.WhileDAHwasseentoprovidesomedegreeoffinancialriskprotection to beneficiaries, there were concerns about its sustainability in Nigeria amidstdwindlingdonorfundingnowworsenedbyeconomicrecession. Discussion/Conclusions: As Nigeria grapples with aid transition issues, it needs to strengthenexistingmechanismsforaidcoordination, jointmonitoringandaccountability for results,whileaddressing inequitiesandensuringvalueformoney.Strengtheningpublicfinancemanagementand related systemscanpotentially increasedonorconfidence in thecountry’s systemmakingcentralizedpoolingofdonorfundsapossibility.

The impact of aid on health outcomes in Uganda

TonnyOdokonyero,RobertMarty,TonyMuhumuza,AlexTIjjo,GodfreyOMosesEconomicPolicyResearchCentre–SPEEDforUniversalHealthCoverage

Health is a key component of human capital that strongly influences labour productivity,economicgrowthanddevelopment.Inlightoftheimportanceofhealth,thesectorhasattractedsignificantforeignaidhowever,evidenceontheeffectivenessofthissupportismixed.InUgandaand most Sub-Saharan African countries, evidence on the impact of aid on health outcomesremainsanecdotal.

Thispaper combineshouseholdpaneldatawithgeographically referenced subnational foreignaid data (geo-coded data) to investigate the contribution of health aid to health outcomes inUganda. Using a difference-in-differences approach, we find that aid had a strong effect onreducing the productivity burden of disease but was less effective in reducing diseaseprevalence. Consequently, health aid appears to primarily quicken recovery times rather thanprevent disease. In addition, we find that proximity to health aid is highly influential on thehealth gains to individuals. Apart from the impact of aid, we find that aid tended to not betargetedtolocalitieswiththeworsesocio-economicconditions.Overall,theresultshighlighttheimportance of allocating aid close to subnational areas with greater need to enhance aideffectiveness. Channeling aid to the lowest level possible offers an additional advantage ofdrivingtheUniversalHealthCoveragestrategyof“closetoclient”healthsystem.

Foreign aid and the health sector: a case study from the Palestinian national authority

WafaMataria,UniversitéAméricaineduCaire

Thisstudy investigatestheroleofForeignAid (FA)onthehealthsector (HS) inPalestine.FA isconsidereda tool forpromotingeconomicandhumandevelopment.ConsiderableamountsofFAaredirectedtoHealth.TheroleofFAindevelopment,includinginhealth,hasbeenasubjectof debate with inconclusive results on its impact. In the case of Palestine: FA to Palestineincreased in the period following the establishment of the Palestinian National Authority toreachUSD920.24millionin2015.ThePalestinianeconomywasfoundtobedependentonFA,where more than 60% of FA received was used in direct budget support rather than


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development.AlthoughthePalestinianhealthsystembenefitsfromFAcomingtoPalestine,theroleofFAonhealthisunderinvestigated.

Both a descriptive quantitative and a qualitative research approaches were used to explore,describeandexplaintheroles,proceduresandchallengesofFAinthePalestinianhealthsector.Data was collected using both: desk review of official documents and published data byspecializedinternationalorganizations,andthroughsemi-structuredinterviewswithapurposivesampleofthemajorstakeholders inthefield.Datawasanalyzedusingdescriptivequantitativeanalysisandqualitativecontentanalysis.

However, FA for health in Palestine is found to be facing many challenges; including: highinfluencedofdonors’agendas,lackofcommunicationbetweendifferentstakeholders;absenceof effective coordination structures and inclusive discussion platforms; low accountability ofdonors towardstherecipients;andfinally the Israelioccupation,whichresulted inanunstablepolitical situation with a continuous crisis situation rendering the development process verydifficult. These challengesnegatively affect theeffectiveness andefficiencyof FA forhealth inPalestine.

The study concluded that the distribution of FA between sectors in Palestine is contextdependent.IthasbeenalsofoundthatalthoughtheHSinPalestinereceivesaround3%ofFA,FAhas a positive role on the HS in Palestine, it has contributed to the establishment of theinstitutionalstructureandcapacitiesoftheHSinPalestine.Italsocontributedtotheprovisionofhealth services. The effectiveness of FA in Palestinehas been improving. Compliancewith theParis Declaration and its five principles improved. The ability of theMinistry of Health (MoH)personnel to assess the Palestinian health needs and to formulate them into priorities andstrategiesincreasedtheownershipandalignmentofFA-fundedprojects.

An analysis of Domestic and Donor Financing for Maternal, Neo-natal and Child Health in Sub-Saharan Africa

Jacob Novignon*, **Dr Chris Atim, *Dr Eric Arthur: *KNUST / **African Health Economics and PolicyAssociation(AfHEA)

Background: Achieving improvement in maternal, neo-natal and child health (MNCH) is animportant public health objective and key performance indicator of overall progress of acountry’s health sector. Despite efforts to improve theseoutcomes in the Sub-SaharanAfrica(SSA)region,theratesofmaternalandneo-nataldeathsremainrelativelyhighintheregion,at547 per 100,000 live births and 28.6 per 1000 live births, respectively, in 2017 (World Bank2017).Similarly,theregionhasrelativelypoorinfantandchildhealthoutcomes.

Objectives: This study is submittedbyAfHEAasa frameworkpaper to theAERCCollaborativeResearch on Health Financing in Africa. The study sought to analyse domestic and externalfinancingforimprovingMaternalNeo-natalandChildHealth(MNCH)outcomesinSSA.Specificobjectivesare:(i)analysisofthetrendsandpatternsinMNCHfinancinginSSAand,giventhosetrends,askswhatarethepotentialgainstoberealizedfromincreasedfundingoftheseservices?(ii)WhatarethefundinggapsthatneedtobecoveredforSSAcountriestoachievetheSDGsby2030?(iii)IstherepotentialfiscalspacefromdomesticsourcesforMNCHfinancingacrossSSA?

Results:ThetrendandpatternanalysisofMNCHoutcomesinSSAshowedwidevariationacrosscountries. While few countries achieved the MDG health related targets, the majority ofcountries failed to achieve the target. Also, health financing trends showed low resourcecommitmentstohealth inSSArelativetotheAbujadeclarationtarget.Thisresultdemonstratethe need for extra resourcemobilisation and high impact health policy interventions in these


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countriesifsignificantprogressistobemadetowardsmeetingthehealthrelatedSDGstargets.Further,wefoundsignificantgainsfromdomesticfinancing,butalsomodestgainsfromexternalfinancing.Interestingly,privatedomesticfinancingshowedhighergains.OurstudyalsoshowedthatforthecountriesanalysedinthisstudytomeetthesetSDGtargetsby2030,theremaybethe need for progressive incremental cost until 2030. Finally, a combination of different fiscalspace options could be harnessed and prioritised by SSA countries to finance MNCHinterventions.

Conclusion: The results emphasised the need for accelerated commitment by governmentstowardsimprovingMNCHoutcomesinSSAifsignificantprogressistobemadetowardsmeetingthehealthrelatedSDGstargets.Keyamongthesecommitmentsistheneedtoscaleupfinancialresources(especiallydomesticresources)tothehealthsector.


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ParallelSession3

Organizedsession

OS 03 – Strengthening Capacity for Teaching and Learning of Health Policy and Systems Research (HPSR) and Health Economics in Africa: Practical Issues for Educators and Learners

Principal organizer: Dr. Gina Teddy, Centre for Health Systems and Policy Research, Ghana Institute ofManagementandPublicAdministration,P.O.BoxAH50,Achimota,GreenhillCollege.Accra.Co-organizers:ThisorganizedsessionispreparedonbehalfHealthSystemsGlobalTeachingandLearningThematicWorkingGroup.ItwilldoubleasaskillsbuildingactivitytoengageeducatorsinHPSR andHealth Economics on practical issues affecting Teaching and Learning in the fieldbroadly.Listofspeakersinclude:

• Gina Teddy – Ghana Institute of Management and Public Administration, Centre forHealthSystemsandPolicyResearch(CHESPOR),Ghana(Moderator)

• JacintaNzinga-KemriWellcomeTrust,HealthSystemsDivision(Kenya)• LeanneBrady -UniversityofCapeTown,SchoolofPublicHealthandFamilyMedicine,

(SouthAfrica)• TwoFacilitatortobeconfirmed

SecuringPrimaryHealthCareforall toachievingUniversalHealthCoverage inAfricahingesonadvancingthehealthsystemsforallandstrengtheningthecapacityofeducatorsandlearnersofHPSR to address practical issues and advancement in the field. This organized session is aparticipatory skills building activity organized by the Health Systems Global (HSG) ThematicWorkingGroup(TWG)onTeachingandLearninginHealthPolicyandSystemsResearchaimedtodeliberate and support capacities of African educators in Health Systems and Policy Research(HPSR)andHealthEconomics.

Theaimoftheorganizedsessionistoprovideaplatformforeducators,researchersandlearnersto jointly discuss and strengthen their capacity for teaching and learning while addressingpractical issues and challenges facing them. This will cover topics such as how to supporteducatorsacrossmultiplesubjects,fields,languagesontheAfricancontinent;providingcapacitybuildingforleadershipdevelopmentandreflectivepractice;adoptinginnovativeteachingmodesthroughtheuseofaudioandvisualaidsforHPSRandHealthEconomicsteachingandlearning;andcurriculumdevelopmentforHPSRandHealthEconomicscapacitybuildingandteaching.WeproposeaworldcaféstylediscussiononthetopicstoengageparticipantstoenableexplorethevariousthemesandtheirrelevancetopublichealtheducationinAfrica.

Thus,thepurposeoftheorganizedsessionistoprovidetheplatformforkeyactorsinteachingand learning to advance key issues, dilemmas and changes in practice affecting the field to


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informstepstowardssupportingmembersoftheTWG.Aswellashowtopromotecollaborativeteaching across subjects, languages, fields and across the continent for health economics andhealthpolicytowardsstrengtheningourhealthsectoroverall.

Findingsfromthesessionwillbederivedfromthedeliberationsoftheorganizedsessions.Twokey findings are expected from this session: 1) that the sessionwill be used to a network ofeducators inhealtheconomicsandHPSRwith theaimof settingcapacitybuildingagendas forthe continent and 2) to advocate for improved teaching and learning in HPSR and HealthEconomicsthroughcollaborativeprocessacrossthecontinent.

Abstractofeachpaper(SummaryofeachPresentation/Activity)

This skills building sessionwill facilitate learning frompractice and lessons that is inclusive forboth educators, researchers and learners of HPSR. It will create the space to engage thoseteachinginHPSRandHealthEconomicstoopenlyandmutuallydevelopstepstowardsadvancinghealthsystemforallbybuildingrelationshipsforabroaderlearningcommunityofcolleaguestodevelopthefield.Examplesofthemesguidingthediscussionsincludebutnotlimitedto:

• TeachingandLearningacrossmultiplefieldsforHPSRandHealthEconomics–Dr.GinaTeddy. This theme will explore the prospects and challenges associated withcollaborativeactivityamongeducatorsonthecontinentbeitforresources,materialsorexpertise through exchange, mentorship or any other means deemed appropriate tobuildcapacityonthecontinent.

• Leadership development and reflective practice in HPSR – Dr. Jacinta Nzinga - KemriWellcomeTrust,HealthSystemsDivision(Kenya).Thefocusofthisthemeistoaddressfundamental issuesaround leadership capacitybuilding inHPSRandHealthEconomicsforleaders,practitioners,policymakersandresearchersintheircountriestoenablethemanticipate,respondandaddresschallengesintheircountries.

• Usingaudio-visualaidsinteachingandlearningHPSR–Dr.LeanneBrady-UniversityofCapeTown,SchoolofPublicHealthandFamilyMedicine,(SouthAfrica).Thisthemewillbe activity packed exploring the trends, significance and multiple resources availabletowards using audio-visual aids in teaching HPSR and Health Economics and thepresentationofresearchfindingsinthefield.

• How do we support each other for the teaching and learning of HPSR and HealthEconomics across the continent, subjects, fields and language (Facilitator to beconfirmed).ThisdiscussionisanexplorationtowardsthevariouswaysthateducatorsofHPSR may support each other through networking, shared resources, community ofpractices,etc.andtheconcretestepstowardsachievingthematacountry,regionalandgloballevel.

• Syllabi and coursematerials development and pedagogy approaches for teaching andlearningHPSR–(Facilitatortobeconfirmed).Oneofthechallengesfacingeducatorstheworld over is the appropriateness of their curriculum to enable them to develop therightcompetenciesrequiredbytheirlearners.Thisdiscussionisagreatplatformtowardsexploringtheappropriatewaystoaddresstheseissues.

This is an open discussion and we expect participants to provide opportunities for mutualexchange, experiential learning, individual and group engagement. The session is open to allconferenceparticipantsinterestedinteachingandlearningHPSR.Bytheendofthesession,wehope to build a network of educators in health economics and HPSR with the aim of settingcapacitybuildingagendasforthecontinent.

Abstract #1 Teaching and Learning across multiple fields for Health Policy and Systems Research (HPSR) and Health Economics (HE)


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Presenter – Dr. Gina Teddy, Centre for Health Systems and Policy Research, Ghana Institute ofManagementandPublicAdministration(GIMPA).

Itisincreasinglynecessaryforpublichealtheducationtoberelevant,practicalandembeddedinthe health and related fields. Learners require a multi-disciplinary perspective, skills andcompetenciestobuildtheircarrierinpublichealthandtomakethemoperableinawidevarietyof fields and expertise. Educators therefore, must pay greater attention to these needs intraining and developing leaders and professionals for the health sector. The responsibility toteach learners and professionals to bring these perspectives, competencies and skills to theirwork in thehealthand related fieldshas implicationonhow theyaddress complex challengesfacing the health system overall. Health Systems and Policy Research (HPSR) and HealthEconomics (HE) is an emerging and dynamic field under public health characterized by milti-disciplinaritytoenable learnersbetterconceptualizedknowledgeandbuildcapacitytoaddresscomplexproblems.Gainingmultidisciplinaryperspectivesand competencies inHPSRandHE iscriticalforlearnerstonegotiateandappreciatethenatureofthehealthsystemwhileremovingthedisciplinaryfiltersthatlearnersbringtograduatehealtheducation.

The Health Systems Global Teaching and Learning Thematic Working Group is leading thediscussion on effective teaching and learning across multiple fields for field building HealthSystemsandPolicyResearchspecificallyandpublichealthoverall.Increasingly,professionalsandgraduateswhodonotexhibitthesecompetenciesarecriticizedforlackingcohesionandcapacitytoappreciatethecomplexsolutionsandprocessesofaddressingtodaypublichealthproblems.HPSRandHEcurriculummustbeembeddedtoenable learners toappreciatethecrosscuttingnature to address routine challenges. Yet learning throughmultidisciplinary field is oneof thebiggestproblemsfacinggraduatestudentsinpublichealthandHPSR.

InaseriesofwebinarsandworkshopsbytheT&LTWGonthesubjects,itbecameevidentthateducators acknowledgemulti-disciplinarity as a core competence for HPSR and HE education.Educatorsareusingvariousstrategiestosupportmultipleperspectivesinpublichealth.Commonamong these strategies are the use of: case studies, embedded learning and problem-basedapproach, the use of multi-disciplinary frameworks and concepts, workplace learning andpractical experience, aswell as applyingprinciples fromdifferent fieldsand subject areas. Thechallenge however is that, learners find it difficult to shift their perspectives form the narrowsciencefieldstoaccommodatethesemulti-disciplinaryperspectives.Thesediscussionswillbringtogethereducatorstodeliberateonthebestsupportforlearnersandcontinuetobuildinterestinhowmulti-disciplinarityimpactteachingandlearninginAfrica.

Abstract #2 Using audio-visual aids in teaching and learning Health Policy and Systems Research (HPSR) and Health Economics (HE)

Presenter - Dr. Leanne Brady - University of Cape Town, School of Public Health and FamilyMedicine,(SouthAfrica)Abstract:Thecalltomaketeachingandlearningmoreinnovative,scientificandlearner-centeredfor public health education is a primary debate inHealth Policy SystemsResearch (HPSR) andHealthEconomics(HE).Thisistoenableaddresstherapidlychangingneedsofthehealthsectorandthechallengesfacingpractitionersandresearchers inthefield.VariousmethodsandtoolsarebeingusedintheteachingandlearningofHPSRandHE,howevertheroleofaudiovisualaidsisundeniablycritical.TheHealthSystemsGlobalTeachingandLearningThematicWorkingGroupis leading the discussion and advocacy for the use of audio-visual aids, exploring currentpractices, adapted and their impact on teaching and learning HPSR and related subjects likeHealthEconomics.


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FollowingasimilardiscussionattheGlobalSymposiumheldinLiverpoolinJuly2018,itbecameevidentthattheuseofaudio-visualaidfacilitateslearningbycreatingtheabilityforlearnerstobetter retain knowledge, interact with the teaching and learning materials and transferknowledge innovativelywhilemaking senseof the field. Theuseof variousmedia techniquessuchas:videostapes,documentaries,pictures,photodiaries,powerpointpresentations,films,posters, radios, audio-tapes, etc. are employed asmay be appropriate to the subjectmatter.However,theuseofthesematerialshavebothmeritanddemerit,theireffectiveapplicationtoHPSR and HE is based on appropriate selection of various aids and their simultaneous use tomakethembeneficialtothelearners.ThisorganizedsessionwillfurtherexplorethespecificcaseforAfrica intermsofeffectivenessuseofaudio-visualaidforHPSRandHEspeciallyandpublichealtheducationoverall.

Abstract #3 Leadership development and reflective practice in Health Systems and Policy Research (HPSR)

Presenter–Dr.JacintaNzinga-KemriWellcomeTrust,HealthSystemsDivision(Kenya).

Leadership development is a topical issues in Health Systems and Policy Research (HPSR) andHealth Economics (HE) education, research and advocacy. Reflective practice is increasingly acorecompetenceforeffectiveleadershipdevelopmentparticularlyforHealthSystemsandPolicyResearch.Reflectionbyhealthmanagersandleadersarecriticalforthemtodeliverandhandlecomplex andmulti-culturalworkplace development. The health systems in LMICs needs to beresilient in thecontextofchronicstressorsorchallenges (resourceconstraints, constantpolicychange)andsuddenshocks(epidemics,dramaticpolicychangeorpoliticalupheaval),aswellasto be responsive to the priorities and needs of patients and the broader public. Frontlineproviders and their immediate managers are key actors in complex health systems, andthereforecentraltodevelopasystemresilienceandresponsivenessrequireleaderswithcertaincore competencies. But how,where andwhen one develop such reflective practice skills as ahealth leaders is not universally agreed on despite the general agreement on its relevant tomodernleaders.

The Health Systems Global Teaching and Learning Thematic Working Group through thisorganized session with further the discussions of the use of reflective practice as a corecomponentandcompetencyforpublichealthleadershipdevelopmentandexplorestrategiesforincorporatingreflectivepracticeinHPSRandHEeducation.Thisdiscussionwillfocusontheneedfor reflective practice, strategies for incorporating reflections in public health leadershipeducation, identify areas and themes for reflections, assessment of such strategies andembeddingittotheroutinepracticesofhealthleadersandpractitioners.

PreliminaryreportfromthediscussionsattheGlobalSymposiumheld inLiverpool inJuly2018showsthatreflectivepracticeisasoftcommunicationskills,yetprovideenoughopportunityforanalytical thinking and problem solving. Reflecting on routine or chronic problems, new ideasandpractices in thehealth sectors is important tounderstandhealth systems complexities. InAfricaparticularly,thecomplexanduncertainhealthsituationcouplewithroutineshortagesandchallenges thatmakes navigating the health systemsdifficult require leaders to be responsiveandresilienttosomeoftheproblemsandtheirabilitytounderstand,appreciatedandgettotheroot of these challenges make reflective practice fundamental to all leaders. The T&L TWGintend to further explore how reflective practice in African impact on leaders’ ability to solveproblemsandimprovetheirroutinepracticesashealthleadersandworkers.


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Abstract #4 How do Educators Support Each Other in Africa for HPSR and HE Education and what pedagogical approach can we use to improve curriculum

Presenter–AyatAbugla,TrinityCollege,Dublin(Ireland)

HealthPolicyandSystemsResearchunlikeHealthEconomicsandpublichealthisconsideredasanemergingfieldthatdrawsonabodyofknowledgefromvariousdisciplines.However, inthelast decade the field is gaining momentum and popularity for its its contribution towardsstrengtheningthehealthsystemsofcountriesacrosstheglobe.Despitetheseachievementtherearesomedisparityinunderstandingofthefieldasthereareineducationandcurriculumguidingthe field. The session will also explore ways of engaging educators to support each other inbuilding the field of HPSR and creating shared resources such as curriculum and teachingexperiences. The challengeof sharing knowledge, experienceand resources toenable supportHPSRacrosstheAfricancontinent,subjects,fieldsandlanguageisimportanttousingthefieldtostrengthencountry’shealthsystems.Thisdiscussionwillbebasedonexploringthevariouswaysthat educators of HPSR may support each other through networking, shared resources,community of practices, etc. and the concrete steps towards achieving them at a country,regionalandgloballevel.

The Health Systems Global Teaching and Learning Thematic Working Group through thisorganizedsessionalsonotedthatoneof thechallenges facingeducators theworldover is theappropriatenessoftheircurriculumtoenablethemtodeveloptherightcompetenciesfortheirlearners in public health education. This discussion is a great platform towards exploring theappropriatewaystoaddresstheissuesassociatedwithsyllabiandcoursematerialsdevelopmentandpedagogyapproachesforteachingandlearningHPSR.

OS 04 – Approaches for achieving Universal Health Care: Policy Perspectives from Africa and Asia

Organizing Institution: Health Intervention and Technology Assessment Program (HITAP), Ministry ofPublicHealth,ThailandCo-organizers: PRICELESS South Africa, KenyaMedical Research Institute (KEMRI), and Imperial CollegeLondon(ICL),AccessandDeliveryPartnership(ADP),HitotsubashiUniversity Manycountriesacrosstheworldareworkingtowardsachievinguniversalhealthcoverage(UHC)whichisamongtheseventeenSustainableDevelopmentGoals(SDGs).Overtheyears,therehasbeen an expanding need and demand for improved, equitable, and affordable health care forpeopleacrossAfricaandAsia.Forexample,KenyahasannounceditsplantoachieveUHCaspartofthegovernment’s“Big4”agendaby2022;inGhana,anationalhealthinsuranceschemehasbeen implemented with a commitment to achieve UHC by 2030; South Africa has exploredseveral options to implement UHC for its under-insured population; Senegal launched theStrategicPlanforDevelopmentofUHCProgramin2013,aimingtoachieveUHCby2022aswell;and inAsia,Thailand implemented itsUniversalCoverageScheme(UCS) in2002while in2018,Indialaunchedwhatisconsideredthelargesthealthinsuranceschemeintheworld.


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Transformingandstrengtheningprimaryhealthcare(PHC)hasbeencentraltothediscussiononachieving UHC. However, substantial investments are required for making PHC a reality forpopulations,bringingissuessuchashealthfinancingandprioritysettingofservicestothefore.Theexperiencesofaddressing these issuesvaryacrosscountriesandcontinents,yet therearecommonlessonstobelearnedfromall.Forexample,inThailand,thegovernmentinstitutedPHCreformsovertwodecadesbeforeimplementingitsUHCpolicy.

The organized session aims to bring together researchers and practitioners from countries inAfrica and Asia to share their experiences towards UHC for a policy-oriented discussion.Representatives fromKenya,Ghana,SouthAfrica,Senegal,Vietnam, India, thePhilippines,andThailandwillspeaktoatopicrelatedtothesub-themesof theconference(e.g.,healthsystemstrengtheningandkeymethodological changes includingcapacitybuilding inhealtheconomicsandpolicyanalysis)andwillgivecontextofthereform,thechallengesfaced,andlessonslearnedaswellasthewayforward.Theformatofthesessionforbothparts1and2willbeasfollows:amoderator will introduce the topic and panel, after which each speaker will have about 13minutes tomake a presentation and take clarification questions; the rest of the time will beallocatedfordiscussionwiththeaudience.

Thetopicareasforeachspeakerareprovidedbelow(TBC):

Country Topic Speaker (Organization)

Kenya Roleof researchorganizations inbuilding capacityonhealtheconomics

KEMRI

Ghana Applying Health Technology Assessment (HTA) for decisionmaking: Cost-effectiveness management of hypertension inGhana

Ministry ofHealth,Ghana

Thailand Development of the pharmaceutical benefits package usinghealthtechnologyassessment(HTA)inThailand

HITAP

India ReachingtheunreachablepopulationstoachieveUHC TBC

OS 05 – How can health systems be shaped to sustainably address the maternal health needs of the most vulnerable and under-served populations?

What motivates primary health care workers to perform well in resource-limited settings? Insights from realist evaluation of health systems strengthening in Nigeria

Speakercontactdetails:BasseyEbenso,UniversityofLeeds,10.28WorsleyBuildingClarendonWay,Leeds,LS29NL,UK.List of co-authors: Reinhard Huss1; Benjamin Uzochukwu2; Enyi Etiaba2; Ana Manzano1; ObinnaOnwujekwe2;NkoliEzumah2;JosephHicks1;JamesNewell1;TimEnsor1,TolibMirzoev1.1UniversityofLeeds,UK-2UniversityofNigeriaEnuguCampus


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Background: In 2012, a UNGeneral Assembly resolution endorsed the need for an adequate,well-trained,skilledandmotivatedprimaryhealthcare(PHC)workforce,toaccelerateprogresstowardsUniversalHealthCoverage(UHC).Whilethere isgrowingrecognitionthatamotivatedworkforceprovidesqualityhealthcare that in turn improvesaccess toandutilizationofhealthservices,however, information is limitedonkey factors thatmotivatePHCworkers toperformwell,especiallyinresource-constrainedcountries.

Aimsandobjectives:Wepresentemerginginsightsonkeyindividual,organizationalandsystemsfactors that influence workers’ motivation, based on health systems strengthening work inNigeria. The specific objective is to assess which aspects of a Government of Nigeria’s socialprotection programme implemented from 2012 to 2015 (to improve the lives of vulnerablemothers and infants) impacted on workers’ motivation. The programme’s health systemsstrengthening activities included upgrading infrastructure, providing supplies, recruiting andtraining PHC workers (2,000midwives and 10,000 community health workers), and providingincentivestopregnantwomentopromoteaccesstomaternityservices.

Methodology:FromJune2015,weconductedarealistevaluationcombiningdocumentsreview,63semi-structuredinterviews,12focusgroupdiscussionsandsecondaryanalysisoffacilitydata,toassesssustainabilityofprogrammeeffectsinAnambraState,south-easternNigeria.Weusedan analytical framework involving theory testing, verification and consolidation to understandhowtheimplementationcontextshapedworkers’motivation.

Keyfindings:Acomplexinterplayofindividual,organisational,systemandsocietalfactorsduringprogramme implementation, affected staff motivation in Anambra State. Individual-levelmotivators were PHC workers’ love of their vocation and welfare of patients. Organizationalmotivators included on-the-job training, supportive supervision and increased availability ofstaff, equipment and supplies at health facilities. Societal motivators included communityappreciation of workers’ roles. Though withdrawal of programme support from 2016 causedsignificant material resource and staff shortages at organizational level, yet, individual andsocietal motivations were sustained. Prominent demotivators were lack of security and staffaccommodationatfacilities,whichincreasedworkers’vulnerabilitytoattacksandreluctancetoworkatnight.Otherdemotivatorswerepoorworkforcepoliciesthatpreventedreplacementofretiredworkers,andlackofambulancestorefercomplicatedcasestospecialistfacilities.

Main conclusions: Lack ofmaterial resources and security constrained themotivation of PHCstaff to provide essential, round-the-clockmaternity services, thereby hindering attainment ofUHC.Werecommendcontext-specificinterventions,includingimprovingworkforcesecurityandfeasiblechangesinpolicy,toimprovestaffmotivationandensurequalityPHCservices.

How secure are primary health care facilities to provide services for the vulnerable population?: Experience of providers in a maternal and Child Health programme

Speakercontactdetails:EnyiEtiaba,CollegeofMedicine,UniversityofNigeria,EnuguCampus.List of co-authors: Benjamin Uzochukwu1; Bassey Ebenso2; Uju Agbawodikeizu1; Ana Manzano2;UgochukwuOgu1;ReinhardHuss2;ObinnaOnwujekwe1;NkoliEzumah1;JosephHicks2;JamesNewell2;TimEnsor2,TolibMirzoev2.1UniversityofNigeriaEnuguCampus2UniversityofLeeds,UK BackgroundMaternal andChildHealth (MCH) is apriority inNigeria.Althoughmortality ratesdeclinedintheMDGyears;Nigeriadidnotmeettargets4and5.Accesstoservicesremainsoneof key challenges.Abundant literature exists on supply anddemand sidebarriers to providingand accessing proven effective interventions. However, little literature exists on how security


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within health facilities affects provision and use of services, especially by vulnerable pregnantwomenfromsocio-economicallydisadvantagedbackgrounds.

TheNigeriangovernment, addressed this throughaprogrammewhichaimed tomitigatebothdemand-andsupply-sidebarrierstoMCHservicesfortheunderservedpopulation.During2012-2015,theprogrammetrainedanddeployedmidwivesandcommunityhealthworkers(CHWs)inprimary healthcare facilities; upgraded infrastructure (including perimeter fencing in somefacilities); provided supplies and financial incentives to pregnant women to access and utilizeservices. A novel group of CHWs; village health workers, were also trained and deployed tomobilisepregnantwomenandassistthemtoaccessservices.

Aim of the study was to evaluate the effectiveness of these interventions towards providingequitableaccesstoservicestotheruralandunderservedpopulation.

MethodsThison-goingstudyemploysaphasedmixed-methodsRealistEvaluationapproachtoassesshowandunderwhatcircumstancesprogrammeworkedtoachieveoutcomesinAnambrastate, southeast Nigeria.We conducted in-depth interviewswith facilitymanagers and healthworkers. Specific programme theories, showing causal pathways of change, have beencontinuouslyvalidatedandrefinedthroughoutdatacollectionandanalysis.

KeyFindingsTheprogrammehadupgradedfacilitiesandwithhelpofthecommunityattemptedto keep facilities secure, for example through erecting perimeter fences and deployment ofwatchmen.However,mosthealthworkersfelt insecureatnight,duetolackofsecurityguards.Asaresultmosthealthworkerswhowereallfemaledidnotfeelconfidenttoprovideservicesatnight. The sense of lack of security had detrimental implications for achieving programmeoutcomes,oneofwhichwastoincreasefacilitydeliveriesbyskilledbirthattendants.

ConclusionPoor security contributed to lackof feelingof safety by this vulnerable populationgroup and this directly influenced provision of round-the clockMCH services in an otherwisewell-fundedandequippedprogramme.Giventhatsignificantproportionofdeliveriesfallduringnighttime,ensuringadequatesecurityatnightwillcontributetoround-the-clockMCHcareandthereforecanhelpaddresstheneedsofmostvulnerablepopulations.

Costs and sustainability of a novel Community Health Workers programme in improving Mother and Child Health in Nigeria

Speakercontactdetails:ObinnaOnwujekwe,HealthPolicyResearchGroup,UniversityofNigeriaNsukkaCo-authors:TimEnsor1,BenjaminUzochukwu2,UcheEzenwaka2,AdaobiOgbozor2,ChinyereOkeke2,EnyiEtiaba2,ReinhardHuss1,BasseyEbenso1andTolibMirzoev11UniversityofLeeds,UK2UniversityofNigeriaEnuguCampus Background: A recent health intervention that was undertaken in Nigeria was the SubsidyReinvestment and Empowerment Program/ Maternal and Child Health (SURE-P/MCH)programme,whichhadbothsupplyanddemandcomponents.Thefundingfortheprogrammeendedin2015,butthereistheneedtoprovideevidenceonitsperformance.Hence,thisstudyprovides evidence on the costs and cost-effectiveness of the intervention, which has directbearingon its sustainability and scalingupof communityhealthworkerprogrammes forMCHinterventions.

Methods: The studywas undertaken inAnambra state, southeastNigeria. Cost andoutcomesdatawere collected from three clusters; (1)With the SURE-PMCH intervention; (2)With theSURE-PMCHintervention+CCTand;(3)WithouttheSURE-PMCHintervention.Costswerefortheyear2014.Informationwascollectedfromrelevantkeyinformantsandfromtherecordsinhealth facilities, local government councils, and the state ministry of health. The costs werecategorizedinto:personnel,infrastructural(capital),drugsandconsumables,overheadandCCT


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costs.DataontheoutcomesoftheinterventionarebeingcollectedusingacommunitysurveyinthethreeclustersandtheresultswillbeavailableinJuly2018.

Key Findings: The highest total annual cost was incurred in the SURE-P +CCT facilities(93,643,613 Naira: US$307,028) and the least cost was incurred by the control facilities(52,717,114NairaUS$172,843). The clusterwith just the SURE-PMCH incurred a total annualcostof79,343,727Naira(US$260,143).ThehighestcontributorstocostsintheSURE-Pfacilitieswere frompersonnel costs and drugs and consumable. The cost on infrastructurewas almostuniformacrossthethreesites.TheeffectivenessoftheinterventionsincreasedmovingfromtheSURE-PCCTcluster to theSURE-Pnon-CCTcluster to thecontrolcluster, forANCanddelivery,butnotforPNC.

MainConclusion:ThereisawidevariationintheannualcostonMCHservicesacrossthethreeclusters. The findingof overall positive incremental cost analyses from theCCT cluster to thenon-CCT SURE-P cluster to the control clusterwere expectedly because of the higher level ofactivitiesintheSURE-PCCTandnon-CCTclusterscomparedtothecontrolcluster.Thecostsandconsequencesshowthatthereareefficiencygapsbutalthoughtheprogrammecanbeusedtoimprove access to MCH services, the relatively most costly CCT cluster calls to question thesustainabilityoftheCCTcomponent,especiallyifrunasroutineprogramme.

OS 06 – Strengthening health systems through the application of health financing progress matrices: country experience

Principalorganizer:MatthewJowett,WHOGenevaCo-organizers:uGraceKabaniha,WHOAFROChairandmoderator:DrGraceKabaniha,WHORegionalOfficefortheAfricanRegionSessionabstract:

OverthepastdecadealargenumberofcountriesintheAfricanregionhaveputsignificanteffortinto the design and implementation of health financing reforms, for example through thedevelopmentofhealthfinancingstrategies.Butwhenwelookclosely,howconsistentarethesestrategieswithglobalevidenceonwhatworkstoimproveaccesstoessentialhealthservicesandfinancial protection for patients? To what extent are the values and objectives of the globalmovementforuniversalhealthcoverageactuallytranslatingintohealthfinancingpolicieswhichareconsistentwiththeevidence?Arecountriesdesigningandimplementingpolicieswhichwillleadtobettereffectivecoverage,andprogresstowardsUHC?Finally,howcancountriesassessmoresystematicallywhetherthepoliciestheyareconsidering,developing,orimplementing,willleadtorealimprovementsinaccesstoservicesandfinancialprotection?

Tohelp countries to answer thesequestionsWHOhasdevelopeda series ofHealth FinancingProgress Matrices which provide a framework for such an assessment, which is largely aqualitativeexercise.Basedonexistingknowledgeglobally,boththeoreticalandempirical,asetof questions have been developedwhich countries can use to discuss, reflect, and ultimatelyassesshealthfinancingpolicyintheircountry.Followingconceptualdevelopmentandtestinginselectedcountriesthroughout2018andearly2019,theprogressmatricesarenowbeingusedinanumberofcountries,someofwhichareprofiledinthissession.


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PAPER 1: An overview of the Health Financing Progress Matrix: a systematic approach to assessing policy developments at the country level

Presenter:MatthewJowett(WHOHeadquarters)Aimandobjectives:Thispresentationwilldescribethemotivation,andevolutionofaseriesofhealth financing progress matrices over the past 18 months; building from existing healthfinancingframeworksandarelatedsetofguidingprinciples,matriceshavebeendevelopedforthecorefunctionsofrevenueraising,pooling,purchasingandbenefitdesign;additionalmatriceshavebeendeveloped to assess thepolicydevelopmentprocess, public financialmanagement,andgovernanceissues.Eachmatrixcontainsanumberofquestionswhichcapturefeaturesofahealthfinancingsystem,consideredtobeimportantforahealthsystemtomovetowardsUHC.Auser-friendly instrument to guide users, prompt questions, and provide rapid heatmapsummarieshasbeendevelopedtohousethematrices.

Key findings: Whilst the progress matrices have been developed to shine a light on healthfinancingpolicydevelopmentsandsupportanassessmentofwhethertheseareconsistentwiththeobjectivesandgoalsofUHC,theyalsosupportbroaderstrategicplanningandprioritynextdirections.Therobustnatureofthematrices,intermsoftheexplicitconnectionbetweenasetof guiding principles and the questions or criteria used to guide both discussion and anassessment of existing policies, offers something additional to existing assessment tools. Theprogressmatricesaimtobecomprehensiveinscope,ratherthandepth,capturingtheessenceofongoing reformsand judging theirconsistencywithUHC; in this sense theycomplementothermorein-depthassessments.

PAPER 2: Strengthening health financing in Tanzania: priority actions identified by the Progress Matrices

Presenter:Ms.JanetKibambo,SeniorEconomist,MinistryofHealth,TanzaniaAim and objectives: According to the current arrangements, all citizens of Tanzania areautomatically entitled to access services in government health facilities. In practice, however,patients incur high out-of-pocket payments due to widely present user fees, especially forcurative services and medicines. Several insurance schemes exist, organized by employmentstatusandtype,includingamandatoryschemeforsalariedcivilservants(andtheirdependents)which provides the most generous coverage but reaches only 6% of the total population.Community health funds (CHF) cover less than 25% of the total population and offer a verylimited package of services, providing little protection from impoverishing and catastrophicpayments. To address these issues, over the past five years a comprehensive and ambitioushealthfinancingstrategyhasbeendevelopedwhichwouldresult inasinglenationalpoolwithunifiedproviderpaymentmethodsandaminimumbenefitpackageaccessibletoallTanzaniansregardlessoftheirincomeoremploymentstatus.Givenitsambitiousnature,thestrategyisyettobeadoptedandimplemented.

In themeantime,however,many important incremental policy changeshavebeen introducedwith the intentionofprovidinga less fragmentedandmoreequitablehealth financingsystem.These changes are difficult to capture through standard evaluation approaches andmeasuresfocusingonchangesinhealthoutcomes.Inthiscontext,theprogressmatriceswereappliedtoassess whether these incremental changes in provider payment methods, health informationsystems,andpublicfinancialmanagementwereconsistentwithUHC.Theyalsoformabaseline


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for continuedmonitoring of health financing policy reforms and provide direction for furtherpolicyengagementandsupport.

Keyfindings:Theapplicationofthematriceshighlightedqualityofcareasakeychallengeinthecountry. Among the three UHC goals it is the one in which least progress has been seen.Coverage (utilization relative toneed) is alsoan important challenge.Among the intermediateobjectives, equity in finance is the key challenge, resulting from existing rules related tointergovernmental fiscal transfers and fragmentation in pooling and purchasing. While someprogresshasbeenmadewithdirecthealthfacilityfinancing,recognitionofprovidersasspendingunits intheChartofAccounts,andintroductionofcapitatedpaymentsforat leastaportionofpublic funds significant challenges remain as identified through these matrices. It will beimportanttocontinueusingthesetomonitorprogresstowardsUHCinTanzania.

PAPER 3: Strengthening health financing in Uganda: priority actions identified by Progress Matrices

Presenter:BrendanKwesiga,WHOUgandaAims and objectives: Uganda was a pioneer in its attempt to address financial barriers tohealthcarethroughtheabolitionofuserfeesanddeclarationoffreeaccesstohealthservicesatpublic health centres and hospitals in 2001. Overall, however, financial protection did notimprove, with out-of-pocket payments remaining high and a persistent challenge across thehealth system. Since 2004,Uganda hasmade a concerted effort to design and implement (tovaryingdegrees)healthfinancingpoliciestoimprovefinancialprotectionandservicequality,andalso to address problems of inefficiency in the health system. The development of a healthfinancing strategyhas focusedon introducing amandatoryhealth insurance scheme, and alsoperformance-basedfinancingwhichhasnowbeenscaledupnationwide.

Key findings: the application of the health financing progressmatrices in Uganda highlightedseveralissuesintheoveralldesignofthehealthfinancingsysteminUganda,despitenumerousreform attempts. Revenuemobilization is still dominated by high out-of-pocket spending andexternal financing; limited progress has been made in addressing the challenges offragmentation in the way funds for the health system are pooled, and the inefficiencies inspendingthatresult.Whiletherehasbeenremarkableprogressintheimplementationofpublicfinancialmanagementreforms,resultinginapositiveimpacti.e.greaterbudgetexecution,thereremain challenges in ensuring financial accountability and value for money in the use ofresources.Uganda’sNationalMinimumHealthCarePackage (UNMHCP) is very extensivewithfew exclusions, and the process of prioritization is not explicit in terms of the benefits andpopulationentitlementfunded.Duetolimitedpublicresourcesthisresultsinimplicitrationing,with the poor and vulnerable unable to access quality health care. Passive purchasingarrangementscontinuetopredominateandunderminedthecountry’seffortstoimprovevaluefor money. However, there has been a systematic attempt to introduce performance-basedfinancing over the last 15 years. As a way forward, the country has proposed to accelerateefforts in reduction of the out of pocket payments, fragmentation and scaling up ofperformance-basedpaymentasapurchasingmechanismforthecountry.


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OS 07 – Strategic purchasing for universal health coverage: the role of aligned mixed provider payment systems

Presentation 1: A Guide and key questions to assess a Mixed Provider Payment System (MPPS)

(byInkeMathauerandFahdiDkhimi,WHODepartmentofHealthSystemsGovernanceandFinancing AimandobjectivesThepurposeoftheanalysisofMPPSistoinformandimprovethenationalpolicy dialogue on purchasing. The results of such an analysis serve tomake the case for anddraw attention to the need of aligning paymentmethodswithin and across purchasers as animportantsteptowardsstrategicpurchasing.

Approach The Guide adopts an explicit systemic perspective and focuses on the providerpaymentmix:itisnotaboutoneinstrumentoronepaymentmethod–whatmattersishowalltheseindividualpaymentmethodscometogetherandwhethertheygenerateacoherentsetofincentivesat the levelofproviders thatworks towards theUHCgoals.ThissystemperspectiveputsstrongemphasisontheproviderperspectiveandcombinesitwithapurchaserperspectivesoastolookatthecombinedeffectsontheoverallUHCobjectives.

Contentof theguideThefirstpartof theGuideexplainswhataMPPS is,whythismatters forUHC, and how this may result in undesirable provider behaviors such as cream skimming orresourceshifting.Subsequently, it looksathowsuchbehaviorsmayaffect theUHCobjectives,i.e. efficiency, equity, financial protection and quality. It presents the overall methodologicalapproachoftheassessmentandprovidesindicationsonhowtoundertakesuchanassessment.

Part 2 of theGuide contains a detailed set of guidingquestions to direct the assessment of acountry’sMPPSwithregardstothefivekeystepsoutlinedbelow:

a) Panorama of the Mix Provider Payment System: mapping exercise including relevantinformationontheoverallcontext, thevariouspurchasersandproviders,aswellas themultiplepaymentmethodsinuse;

b) Assessment of the incentives created by the mixed provider payment system incombinationwith the levelofproviderautonomyandmanagerial flexibility,howtheseincentivespotentiallyinfluencethebehaviourofeachprovidertypeandhowtheyaffectUHCobjectives;

c) Assessmentof theothereffectsof themixedpaymentsystemacross thewholehealthsystem;

d) AssessmentoftheeffectsofgovernancearrangementsonthefunctioningoftheMPPS;e) Developmentofpolicyoptions inorder to improve theoverall coherenceof theMPPS

anditsalignmentontheUHCgoals.

Presentation: Case study from Burkina Faso

Introduction: Despite scarce resources, the government of Burkina Faso invests a significantshareofitsbudgetinhealthinordertofinanceambitiouspoliciese.g.thefree-healthcarepolicyformothersandchildrenunder5.However,severeresourceconstraints forcethegovernmenttomove towards enhanced strategic purchasing, in order to yield themaximum return on itsinvestmentinhealthandtosecuresteadyprogresstowardsUHC.


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Objectives:ThegovernmentoptedtoinitiatethedialoguearoundStrategicPurchasingthroughasetofstudies.Onefocusofinterestwasthecurrentmixedproviderpaymentsystem,whichwasassessedintwosteps:

• Amappingexercisethatdescribedthecurrentmixedproviderpaymentsystem,i.e.themultiple payment methods used by the various purchasers in the Burkinabé healthsystem;

• An analytical exercise that explored the causal chain between paymentmethods, thegenerated financial incentives, the behavioral responses of the PHCproviders – publicand private – and the induced consequences on the health system’s objectives – i.e.equity,efficiencyandquality.

Methodology:Buildingon theWHOguidancedocument, thestudycollated findings fromfourmaindatacollectionmethods:adocumentreview,asetof interviewswithkeystakeholdersatnational level, an analysis of data extracted from theNationalHealth Information Systemandpreviousstudies;twocasestudieswhichallowedtozoominontheMPPSanditseffectsintwodistricts.

Results:Thestudyshed lightonahighlycomplexmixofpaymentmethods inplace inBurkinaFaso.

It made surfaced a strong disconnect between the intended incentives and those created inreality.Keyfactorsthatexplainedsuchanimplementationgapare:

• Asetofenablersfor/preconditionstopositivebehavioralresponsewhichwerenotmetat the time of the study – e.g. provider’s lack of autonomy, but alsoweak provider’sprocurement;

• A set of payment features which are – according to the actors – determinant ininfluencingthebehavioralresponse:predictabilityandregularityofpayment.Therathererraticimplementationprocessofpaymentreformsoftenkilledtheintendedincentivesintheegg;

• AlackofgovernancestructuresandmodalitiesfortheMPPS,whichledtoill-coordinatedpaymentmethods,sendingrathercontradictorysignalstoproviders.

Conclusion:Governanceissuesemergedasdeterminantinordertoharnessthepotentialofthecurrentpaymentmethodsinplace.Theyshouldbetackledinthefirstplace,beforeintroducingany“new”paymentmethods.

Presentation 3: Country case study from Egypt

byAhmedKhalifa(WHOEgypt),NevineElNahass(MOHEgypt)andMaiFarid(MOF,Egypt)

Introductionandbackground:ThepromulgationofthenewUniversalHealthInsuranceUHILawstimulates major progress towards achieving Universal Health Coverage UHC. By the fullimplementation, it is envisaged that all Egyptianswill be coveredwith quality health serviceswhile ensuring adequate level of financial protection. This country study aimed to inform theimplementationprocessoftheUHIbyanticipatingthestrengthsandpossiblechallengesaswellas developing options to support the establishment of an aligned mixed provider paymentsystem.

Methods:Amixedmethodsapproachwasapplied, includingdocument review, inparticularoflegal provisions relating to the previous health financing system and the new architecture, aswellasinterviewsanddiscussionswithkeystakeholders.


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Results: Even though the Law and the Bylaw do not specify the payment methods for UHIcovered curative health services, there seems to be an implicit understanding of using casepayment for inpatient care combined with fee for services, and capitation payment for theprimarylevel.

The curative health services are covered by the UHI and will be paid through output-basedpaymentmethods(feeforservicepaymentorpreferablycasepayment),whilstpreventiveandpromotivehealth serviceswill be funded (andpaid) through inputoriented, line itembudgetsfrom the Ministry of Health and Population. In view of the incentives set by these paymentmethods, health facilities (and staff), both public and private,may very likely find the formermore attractive There is a hence risk that this leads to undesirable provider behavior, namelyresource shifting to the curative care provision (staff time, attention, medical supplies, etc.),leading to resources shortages (staff timehence longerwaiting time, lack of supplies etc.) forpreventivecare.

Conclusions: The assessment points to the importance of aligning the funding streams forpreventive&promotivecare(line-itembudgeting)andcurativecare(UHIpaymentmethods)inorder to avoid distortions in provider behaviour. If moving away from a budgeting approachbased on line items for preventive and promotive care is not feasible within short time, analternative is toaddapay forperformancecomponent togive incentives tohealthworkers toputmoreemphasisonpreventive&promotivehealthservices. Introducing financial incentivesforcarecoordinationmaybeanadditionaloption.

Presentation 3: Country case study from Malawi

Background:Malawihasmadesomeprogresstowardsuniversalaccesstoeffectiveandqualityhealthservices,thoughmajorchallengesremain.Improvingthepurchasingfunctioniscrucialinordertoeffectivelylinkresourceallocationstoactualpopulationhealthneedsandimprovebothallocativebutalsotechnicalefficiencyofthehealthsystem.Thisisoneofthecoreobjectivesofthe Health Sector Strategic Plan 2 covering the period 2017-2022. Following this decision, areviewoftheMixedProviderPaymentSystemhasbeen identifiedasoneofthemostrelevantoneentrypointstotakethedialogueonpurchasingtothenextlevel.

Methodology:ThestudyappliedtheWHOguidanceforMixedProviderPaymentassessment.

Undertakingtheanalysissystematicallyandcomprehensivelyrequirestheissuestobeexploredbyamixedmethodapproachthatisinitiallyofqualitativenature,butshouldbecombinedwiththe analysis of quantitative data, where possible. The proposed methodology consists of thefollowingactivities:document review, secondarydataanalysis (household surveysandDHIS2),andqualitativeprimarydatacollectedthroughinterviewswithkeystakeholders(bothatnationalanddistrict levels,providersfromthepublicandprivatesector,andfromvariouslevelsofcare(primary,secondary,tertiary),aswellasusers.

ResultsInMalawi,suchreviewrevealstwokeyfindings:

• First, inthepublicsector,mostfinancial flowsreceivedbyprovidersofall levelsofthehealthcare pyramid aremostly input-based, channelled through rigid line-item budgetlines. Budget allocations are typically determined by Treasury based on historicalpatterns.Primaryandsecondarycare is largelypurchasedbydistrictcouncilsbasedoninput-basedlineitems.Performance-basedFinancingisbeingimplementedasaremedyagainst the negative incentives created by these rigid payment methods, with mixedresultssofar;

• Second, intheprivatesector(mostlynon-for-profit),servicesaremostlypaidoninputsforsalaries(lineitembudgetallocatedbytheMoH)andonoutputsfortheconsumables,quasisystematicallythroughcostsharing–i.e.privatepaymentsfrompatients.


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Beyondthedetaileddescriptionofthecurrentsituation,thestudymakesalsosurfaceimportantissuesofmisalignmentsbetween thedifferent incentives, theexistenceof perverse incentivesacross the health system and a lack of any coordination mechanism, a precondition to anyattempttooptimizetheMixedProviderPaymentMix.

Conclusions: Several policy recommendationshavebeendeveloped inorder tomove towardsmoreharmonizedProviderPaymentSystem.

OS 08 – Is a per capita payment system a viable strategic purchasing option for assuring universal access to Primary Health Care in Ghana: What have we learned over time and what is the way forward

*IreneAgyepong,**TimothyEnsor:GhanaHealthService,**LeedsInstituteofHealthSciences

The aim of this session is to presents experiences and lessons from the design andimplementation aswell as aspects of the evaluation of a pilot per capita payment system forprimarycareundertheGhanaNHISbetween2010and2016.ThisisdonetoexplorelessonsforGhanaandotherlowandmiddleincomecountries(LMIC)insub-SaharanAfrica,strugglingwithstrategic payment systems design and implementation to support UHC in the face of limitedresources.Threestartingpresentationprovideinformationoncontext,andprocessesfromtheperspective of the Provider PaymentMechanism Technical steering committee that designedand supported the early implementation of the pilot; as well as exploratory and explanatoryresearch into aspects of the process and intermediate outcomes /effects. The threepresentations are followed by an interactive interview and inputs from panel representingmultiple stakeholder perspectives on the how and why of the processes and outcomes andlessonsand suggestions for theway forward. Thepaneldiscussionalsoexploreswhetherpercapitapaymentsystemscanbeaviableoptionforassuringuniversalaccesstoprimarycare.Thesessionstructureisassummarizedbelow.

(1) Introductorycomments/remarksbythesessionchair(2) Threeinitialpresentationsof10minuteseach(abstractsattached)(3) Interactiveinterviewwithpresentersandamulti-stakeholderpanelonhowandwhyof

the processes and outcomes and lessons from different stakeholder perspectives, andwhether a per capita payment systems can be a viable option for assuring universalaccess to primary care under the NHIS. Facilitated by Ms. Vanessa Offiong, a WestAfricanjournalistwithspecializedtraininginhealthreporting30minutes

(4) Contributions,questions,discussionandinteractionwiththeaudience(25minutes).(5) Closingsummary/conclusionsandcommentsbySessionChair(5minutes)

Abstracts 1: Context and Process of the design and Implementation of a Capitation Pilot in Ashanti Region, Ghana from the perspective of the PPM-TSC: An insider view.

IreneA.Agyepong&PPMTSC


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The Ghana NHIS started implementation in 2004, with provider payment by itemized fee forservice. In response to cost escalation, variable and inequitable fee schedules; the GhanaDiagnosticRelatedGroupings(G-DRG)paymentwas introducedforservices in2008.Medicinescontinued to be paid for by itemized fee for medicine, but a medicine list and fixed pricesperiodically negotiated were introduced. In response to continued rising costs, cumbersomeclaimsprocessingproceduresanddelaysinproviderpayment;Ghanasetouttodeveloppoliciesand programs, and pilot a capitation payment system for primary care in 2010. TheAshantiregion,with 19%ofGhana’s population,was selected for the pilot. A package of outpatientservicesincludingprimarymaternitycare,basiclaboratorytestsandmedicineswasproposedbythe technical policy actors in the Provider PaymentMechanism Technical Steering Committee(PPM-TSC). In response to stakeholder concerns about inadequate knowledge and possiblenegative side effects medicines were excluded from the package pending better evidenceavailability.Maternityserviceswereretaineddespitesomecontestation,becausethedataaboutadministrativefeasibilityseemedreasonablycleartothePPM-TSC.

Abstract 2: The rise and fall of maternity services and medicines as components in the capitation basket:

Dr.AugustinaKoduah

Thispresentationexploresfirstly,howmedicinespartofthebasketofservicesinaprimarycarepercapitanationalhealth insuranceschemeproviderpaymentsystemdroppedoff theagendapriortoapilot implementation intheAshantiregion. Secondly,howandwhy lessthanthreemonths into the implementation of a pilot prior to national scale up; primary care maternalservices that were part of the basket of services in a primary care per capita national healthinsurance scheme provider payment system dropped off the agenda. The studymethodologywasacasestudydesignwith in-depth interviews,observationsanddocumentreviewofmediacontents, reports and meetings records as data collection methods. Data analysis drew onconceptsofpolicyresistance,power,theoryofaccessandarenasofconflict.Duringtheagendasetting and policy formulation stages; predominantly technical policy actors within thebureaucratic arenaused their expertise and authority for consensus building to getmedicinesand antenatal, normal delivery and postnatal services included in the primary care per capitapayment system. Before and during policy implementation, policy makers were faced withunanticipated resistance. Service providers, especially the private self-financing used theirprofessionalknowledgeandskills,accesstopoliticalandsocialpowerandstreetlevelbureaucratpowertocontestandresistvariousaspectsofthepolicyanditsimplementationarrangements–includingtheinclusionofmedicinesandprimarycarematernalhealthservices.Arenasofconflictmovedfromthebureaucratictothepublicasopposingactorspresentedmultipleinterpretationsof the policy intent and purpose and gained the attention of politicians and the public. Thecontextof intensepublicarenaconflictsandcontroversy inanelectionyearaddedtothehighlevelpoliticalanxietygeneratedbythecontestation.TheNationalHealthInsuranceAuthorityinconsultationwith theMinister of Health removed themedicines from the capitation packagebeforepolicyimplementation.Duringtheimplementation,thePresidentandMinisterofHealthrespondedtothecontestationandremovedantenatal,normaldeliveryandpostnatalcarefromthe per capita package. The tensions and complicated relationships between technicalconsiderations and politics and bureaucratic versus public arenas of conflict are importantinfluencesthatcancauseitemstoriseandfallonpolicyagendas.


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Abstract 3: Effect of a per capita payment system on utilization and claims expenditure under the NHIS

Francis-XavierAndoh-Adjei,BronkeBoudewijns,EricNsiah-Boateng,FelixAnkomahAsante,KoosvanderVelden,ErnstSpaan

Introduction: Ghana introduced capitation payment under National Health Insurance Scheme(NHIS) in 2012 with a key objective of controlling utilization and cost. This study sought toanalyse utilization and claims expenditure data before and after introduction of capitationpaymentpolicytounderstandwhethertheintendedobjectivewasachieved.

Methods: The studywas cross-sectional, using anon-equivalentpre-test andpost-test controlgroup design.We did trend analysis, comparing utilization and claims expenditure data fromthree administrative regions of Ghana over a 5-year period, 2010-2014. We performedmultivariate analysis to determine differences in utilization and claims expenditure betweeninterventionandcontrolregions,andadifference-in-differencesanalysistodeterminetheeffectofcapitationpaymentonutilizationandclaimsexpenditureintheinterventionregion.

Results:Growthinoutpatientutilizationandclaimsexpenditureincreasedintheprecapitationperiodinallthreeregionsbutslowedinpostcapitationperiodintheinterventionregion.Linearregression analysis showed that there were significant differences in outpatient utilization(p=0.0029)andclaimsexpenditure(p=0.0003)betweentheinterventionandthecontrolregionsbefore implementation of the capitation payment. However, only claims expenditure showedsignificant difference (p=0.0361) between the intervention and control regions after theintroductionofcapitationpayment.Adifference-in-differencesanalysis,however, showedthatcapitation payment had a significant negative effect on utilization only, in the Ashanti region(p<0.007).Factorsincludingavailabilityofdistricthospitalsandclinicsweresignificantpredictorsofoutpatienthealthcareutilization.

Conclusion:Outpatientutilizationandrelatedclaimsexpenditureincreasedinbothpreandpostcapitationperiods,buttheincreaseinpostcapitationperiodwasatslowerrate,suggestingthatimplementation of capitation payment yielded some positive results. Health policy makers inGhanamay,therefore,wanttoconsidercapitationakeyproviderpaymentmethodforprimaryoutpatientcareinordertocontrolcostinhealthcaredelivery.

(OS 09) Parallel Session 3 – The influence of Cultural Practices in the spread of Diseases: the case of far North of Cameroon

DrTolib Mirzoev,UnitedKingdomUniversityofLeeds

This is anethnographic studywhich reveals the fact that thehealthandhealthcareof a givencommunity intimeandspacemirrorstheworldviewandvaluesofthatculture.Thus,thewaypeoplerelatetonature,otherpeople,time,persons,charity,community,andsoforthhasalotto do with the human mechanism. Consequently sickness behavior determines who issusceptibletoillnessandevenwhoagreetobecomeapatient-sinceonlyaboutonequarterofthe ill persons effectively see amedical doctor. It is therefore through cultural standards that


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one is a patient andwhat it takes to be a patient in the hospital. Thus culture is general butspecific. We would use both qualitative and quantitative methods to put the analysis of thiswrite-up. Meanwhile through participatory observations, interviews, research sampling, focusgroups, questionnaires, life stories and ethnology to collect our data as well as maintainobjectivity and originality of this study.Meanwhile, themain objective is to understand howculture influencepeople’shealthandhealthcarebehaviours.Findings showthateven religiousthoughts on death vary within cultures, and particularly related to hospital-based treatment.Languageandculturalinterpreterscanbeessentialsincetheyaremoreavailablethanrealized,though there are pitfalls in their use. In effect, one must recognize that personality mayovershadowtheculturalandanexcellentconsiderateaffiliationcanbebalanceformanyculturallapses. To that effect, medication and diet necessitate meticulous considerations. Hence, theviewofaphysicalpainandpsychosomaticsufferingvariesfromculturetocultureandinfluencethemind-set and success of care-givers than patients. Althoughour culture is our identity, itwould be knowledgeable to guide members of the community about the different healthsystemsandtheneedtounderstandthatsomecasesofhealthcareneedablend.

(OS 10) Parallel Session 3 – How agent-based modelling can help healthcare policy and planning

Agent-based modelling for health economic evaluations and healthcare policy decisions

DrItamarMegiddo,Chancellor’sFellow,Lecturer-UniversityofStrathclyde

Inthistalk,wewill introduceagent-basedmodels(ABMs)andtheiruseineconomicevaluationof healthcare interventions. ABMs are often used in theoretical approaches with explanatorygoalsinmind.However,theflexibilityofABMsalongwiththeirabilitytointegratediversedatasources also lends to a data-driven approach that can be used to model healthcare withpredictive goals, to informpolicy anddecisionmaking. That is the realmof health-economics,whichhasbeenprimarily concernedwithmeasuring theeffectiveness, value,andefficiencyofhealthcaresystems,services,andinterventions.However,increasingdemandforevidence-baseddecisionmakinggloballyisdrivinganeedforinnovationinthefield.Forexample,mosttrialdataontheefficacyofinterventionscomesfromhighincomecountries,andweneedtocontextualizeevaluations to consider local populations and healthcare systems. Furthermore,we have newgoalsandcriteriainmind:TheUnitedNation’sSustainableDevelopmentGoalshavehighlightedthe importance of measuring the distribution of health in the population and the fairness ofinterventions.WorkingwithABMsprovidesmodellingflexibilitythatcanhelpintheseareas.

OurgoalistounderstandwhetherandhowABMscancontributetohealthcareevaluationsandplanning in sub-Saharan Africa and globally.Wewill use IndiaSim—a data-driven ABM of theIndianpopulationand itsutilizationof thehealthcare system—and itsapplication ineconomicevaluationsasanexample.IndiaSimhasbeenusedtopublishevaluationsofinterventionssuchas public financing of epilepsy treatment, developing water and sanitation infrastructure toreduce the burden of diarrheal disease, and expanding India’s Universal ImmunizationProgramme.Wewill reflecton thechallengesposedbyworkingwithdata-drivenABMs; thesechallenges are particularly acute in low- and middle-income countries, where data is oftenlimited.WewillalsosuggestusefulresourcesforbeginningtoworkwithABMs.


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Robust Analytics for Malaria Policy: What is the Role for Individual-Based Models? ProfDavidLSmith,InstituteforHealthMetricsandEvaluation(IHME)-UniversityofWashingtonMathematicalmodelshaveplayedaroleinmalariaresearch,butthereisareneweddemandforquantitativeadvice thathasputgreaterdemandson theiruse inmakingmalariapolicy. Someaspectsofmalaria canandmustbedealtwithusing simplemodels,but there isalsoa criticalrole for individualbasedmodels,whicharethemostefficientwayofdealingwithsystems likemalaria that are heterogeneous and complex. Malaria transmission involves complexinteractions between hosts, vectors, pathogens, and the interventions put in place to controlmalaria.Acommonthemerunningthroughallofmalariaepidemiologyandcontrolistheroleofheterogeneity. The intensity of exposure and transmission is heterogeneous because of theunderlyingmosquitopopulations.Mosquitohabitatsare spatiallyheterogeneous,andweatherand mosquito ecology establish conditions to support pathogen transmission over both time(e.g.seasonalorephemeral)andspace(e.g. focality). Immunitytomalaria isheterogeneous inpopulations,dependingonageandexposure; immunity tomalariahasapoormemory, and itdevelopsdifferently inpeopledependingon the intensityandpatternsofexposure.Therearemultiplemodes of vector control, and there aremultipleways of using anti-malarial drugs tocuremalariaandreducetransmission.Malariaconnectivityisalsoanimportantfeatureofthesesystems as malaria parasites move around in infected mosquitoes and humans. The policyquestions driving malaria modeling are how to stratify geographical areas for control, whichinvolves1)subdivisionintoareas;2)choosingcombinationsofinterventionsthataretailoredtothespecificconditionsandprogrammaticgoals;and3)coordinatingmalariaacrossareas.Here,wediscuss theuseof individualbasedmodels todesign interventions for forestmalaria in theGreater Mekong System, the role of individual based models for the design of randomizedcontrol trials for mosquito-borne pathogens, and the role of human behavior in malariaelimination.

Health care priority setting in sub-Saharan Africa: what does agent-based models have to offer?

DrJusticeNovignon,SeniorLecturer,SchoolofPublicHealth-UniversityofGhana

Recently,therehasbeenamovetowardspromotingand,inmanycasesinstitutionalizingprioritysettingmechanismswithinthehealthsectorofmanycountriesinsub-SaharanAfrica.Thaturgestemsfromthe increasingphenomenonofdonortransition fromhealthsectoraid,occasionedbytheeconomicgrowthinmanycountries,oftenmovingthemintohigherincomebrackets.

With the need for priority setting comes the need to identify different methodologicalapproachesandwhattheyhavetooffertocontextualizeSSA’sapproachtoprioritysetting.

This presentationwill build on theprevious twopresentations and seek to discuss howABMscouldbeusefulinhealthcareprioritysettingonthecontinent.WewillalsoseektoidentifyanddiscusswhatchallengescouldariseinusingABMs,andwewillengagetheaudienceindiscussinghowtosurmountsuchchallenges.


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OS 11 – Sound decision making – a development partnership for UHC TommyWilkinson,HealthEocnomicsUnit,SchoolofPublicHealthandFamilyMedicine,UniversityofCapeTown,Observatory,SouthAfrica-InternationalDecisionSupportInitiative

Many countries on the African continent are progressing towards Universal Health Coverage(UHC),akeydriverfortheachievem ent of sustainable development goals for good healthandwell-being,reducinginequalityandpromotingeconomicgrowth.

TheUHCjourneyinvolvesfrequentandcontinuoushealthpolicydecision-makingatalllevelsofthehealth systembymultipleactorsand stakeholders.Decisionsandprocessesabout fundingandaccesstoahealthbenefitsandservices(thehealthbenefitspackage,HBP)withinavailablefiscalspacearecriticaltothesustainability,politicalsupportandtrustintheUHCsystem.

The explicit determination of a HBP can provide clarity on eligibility and promote access andexpectationsof ahealth service. It can facilitate a reductionofout-of-pocket expenditure andprotection from health related impoverishment, improved programme budgeting,empowerment of patients and public and a platform for quality improvement. However,determiningwhat interventions and services are included in theHBP requires a coherent andevidence informed strategy, that acknowledges budget availability and accommodatesconsiderationofsocialvaluesandwiderhealthsystemobjectives.

TheroleofdevelopmentpartnersinassistingcountriesdevelopsystemsandprocessesforHBPdevelopment and sound decisionmaking involves iterative change, building on successes andlearningfromfailures.Itrequiresintegratedapproachesandproactivecoordinationwithcountrygovernments and between partners to address persistent challenges to HBP design for UHCincluding available transitions from funding and fiscal space, vertical program integration andstrengtheningprimaryhealthcarebenefitsaccessanddelivery.

ThisorganisedsessionwillhighlighttheworkofdevelopmentpartnersinprogressingUHC,HBPdesign,andevidencefordecisionmaking,andwillelicitrecommendationstoaddresschallengesandbuildonsuccessesthroughactiveparticipationandparticipantdiscussion.Speakersforthesession include the International Decision Support Initiative (iDSI – Kalipso Chalkidou), the BillandMelinda Gates Foundation (HongWang), the Clinton Health Access Initiative (CHAI, RaphHurley), the World Bank (TBC) and AfHEA leadership [request AfHEA exec to nominatediscussant].

Thesessionorganisersarealsoveryopentosuggestionsforfurtherspeakers/representationofinstitutionsandrequestconsiderationforthisorganisedsessiontobepresentedinplenary.


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ParallelSession4-Oralpresentations Parallel Session 4-1 Health financing assessments Do countries that spend relatively more on PHC compared to higher level care have better health outcomes than those that spend relatively more on higher level care compared to PHC?

ChrisAtim*,ZlatkoNikoloski**,DanielMalikAchala**AfricanHealthEconomicsandPolicyAssociation-AfHEA,Accra**LondonSchoolofEconomicsBackground:Primaryhealthcare (PHC)hasbeen toutedasa critical cornerstone forachievinguniversalhealthcoverage(UHC).Indeed,thejustendedAstanaConferenceonPHC,onthe40thAnniversaryoftheAlmaAtaDeclaration,committedallparticipantcountriestoseekPHCforallasthebasisformakingprogresstowardsUHC.

To demonstrate their commitment to PHC as a priority health policy, countries are frequentlyaskedtodoalltheycantoshifthealthspendingfromemphasisonsecondaryandtertiarylevelstowardsthePHClevelofthehealthsystem.YettheempiricalevidencethatlinksafocusonPHCrelatedexpenditurestobetterhealthoutcomesisscarce.

ThisstudyseekstoanswerthequestionofwhethercountriesthatspendrelativelymoreonPHCcompared to higher level care have better health outcomes than those that spend more onhigher level care.Countries fromaround theworld includingsub-SaharanAfricawereselectedbasedondataavailability.Ourapproachisthemultivariatepaneldataregression.

Objectives:1. To find the effects of PHC related expenditures and higher level care expenditures on

healthoutcomes2. To find outwhether countries that spend relativelymore on PHC compared to higher

levelcarehavebetterhealthoutcomesthancountriesthatspendmoreonhigher levelcare.

3. Toassesstheimpactofothersocialdeterminantsofhealth

Expected Results: Our working hypothesis is that a trend analysis of health outcomes andexpendituresonthedifferentlevelsofcarewouldrevealthatcountriesthatspendmoreonPHCwillhavebetteroutcomesthanthosethatspendmoreonhigherlevelcare.Thereasonforthishypothesis is twofold.First,unitcostofPHCservices isusually lowercomparedtohigher levelcareandprior globalevidence (e.g. globalburdenofdisease studies)have shownconclusivelythat many PHC type services such as childhood immunizations, maternal care services, andcommunityintegratedmanagementofchildhoodillnesses(C-IMCI)costverylittleinrelationtotheirbenefits.Second,PHCfocusesonprevention,gatekeeping,earlydetectionandtreatmentwhichcangreatlyreducecostcomparedtohigher levelcare.Wealsoexpect thataregressionanalysiswilllendcredencetothetrendanalysisandrevealresultsthatindicatethatPHCrelatedexpendituresexertsignificantinfluenceonhealthoutcomesmuchbetterthanhigherlevelcareexpenditures.Finally,weexpectothersocialdeterminantsofhealth(SDH)tosignificantlyaffecthealthoutcomes.


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Options for long term sustainable financing of HIV and AIDS responses in Uganda: results of a stakeholder survey

CharlesBirungi,HoimaUniversityCollegeLondon

Introduction:ThefiscalsustainabilityofHIV/AIDSresponsesinUgandaisincreasinglyuncertain.On one hand, overall costs of HIV/AIDS are rising, due to a commitment to achieve universalaccessandthechangingneedforservicesbypeoplelivingwithHIV.Ontheotherhand,thereislimitedavailabilityofdomesticpublicfinancialresources,coupledwithflatordeclininglevelsofdonorsupport(includingfundingtransitionsprojectedonthehorizonsinthenext6–10years).Against this backdrop, a discussion about options to fund the national AIDS response in thefuturebecomesverypertinent.Thisstudyelicitspreferencesamongagroupofkeystakeholders(donors, people living with HIV, service providers, government, academia and HIV-relatedindustry)ontheissueoffiscalsustainabilityofHIV/AIDSresponsesandthefuturefundingofHIVservices, with a view to understanding the different degrees of acceptability between policyinterventionsandfuturefundingoptionsaswellastheirfeasibility.

Methods:Weinvited266individualstoparticipateinanonlinesurveycollectingpreferencesonavarietyofrevenue-generatingmechanismsandcost/demandreducingpolicies.

Results:Wereceived205responsestooursurveyfromallstakeholdergroups.Acrossallgroups,the highest preference was for policies to finance HIV services, and indeed universal healthcoverage (UHC), through public finances. There was a broad consensus not to reallocateresourcesfromsocialsecurity/education.Betweenstakeholders,thereweremarkeddifferencesofopinionbetweenindustry/advisoryandarangeofothergroups,withindustrybeinggenerallymoreinfavourofmarket-basedinterventionsandanincreasedrolefortheprivatesectorinHIVfinancing/delivery.Conversely,stakeholdersfromacademia,government,andcivilsocietywererelativelymoreinfavourofmorerestrictivepurchasingofnewandexpensivetechnologies,and(to varying extent) of higher income/corporate taxes. Taxes on sugar sweetened beverages,ultra-processedfoods, tobaccoandalcoholwereby farconsideredthemostpolitically feasibleoption.

Conclusions: According to this study, policy options that are broadly acceptable acrossstakeholder groups with different inherent interests exist but are limited to public finance(drawnfromordinarytaxrevenues),andexcisetaxesonharmfulproducts.Representativesfromthe private sector tend to view solutions rooted in the private sector as both effective andpolitically feasible options, while stakeholders from academia and the public sector seem toplace more emphasis on solutions that do not disproportionately impact certain populationgroups.

Institutionalization of National Health Accounts: Experience of Mauritius in shaping and implementing policies and strategies

Yogendr'nath Ramful;MinistèredelaSantéetdelaQualitédeVie InstitutionalizationofNationalHealthAccounts (NHA) inMauritius iswellunderwayandfaringwellsince2014.NHAinMauritiusisbasedontheintegrativeapproachandtheSystemofHealthAccounts(SHA)2011.TheHealthAccountsProductionToolfacilitatestheNHAprocess.

ThelatestandthirdroundofNHA(NHA2017)reportsTotalHealthExpenditure(THE)ofRs25.3billiononhealthin2016.GeneralGovernmentHealthExpenditure(GGHE)amountedtoRs11.3billion.PrivateHealthExpenditurewasestimatedatRs14.0billion,outofwhichOutofPocket(OOP)spendingonhealthwasRs11.9billion.NHA2017confirmsthat,despiteprovisionoffree


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qualityservices inthepublicsector,householdsarespendingmuchmoreintheprivatesector.OOPspendingonhealthwhichwasRs10.8billionin2014increasedby10.5%in2016.

NHA2017alsotracksexpenditureondiseases.66.5%ofTotalHealthExpenditure,representingsomeRs16.5billion,wasspentonnon-communicablediseases,withanestimatedamountofRs3.6billionspentoncardiovasculardiseases,Rs1.2billionondiabetes,Rs955milliononcancerandRs1.8billiononinfectiousandparasiticdiseases.

TheinstitutionalizationoftheNHAiscloselylinkedtothenationalhealthpolicyprocessfortheallocation of financial resources, formulation of strategies to enhance the performance of thehealthsystemandformonitoringprogressoftheSustainableDevelopmentGoal3.

NHAReportsareapprovedbyCabinetofMinisters,chairedbythePrimeMinister.ThepreviousNHA 2015was extensively used during budget consultations. It contributed to a hefty rise inbudgetary allocation granted to the Ministry of Health and Quality of Life (MOH&QL),representingan increaseover 33% in FY2018/19as compared to thatof 2014.Consequently,GGHEasapercentageof theGDP rose from2.3% in2014 to2.5% in2016.Governmenthasimplemented severalmeasures to consolidate universal health coverage (UHC). These includedecentralizationofspecializedservicestothecommunity,furtherimprovementofthequalityofcareinpublicinstitutionsandemphasisoncustomercare.Besides,NHAhavebecomeimportanttoolsforprivatestakeholderswhoarekeyplayerstopromotemedicaltourism.

TheNHA2017Report,recommendsthat,forMauritiustoimproveitsUHCIndexfrom64to80,thefiscalspaceoftheMOH&QLhastobegraduallyincreasedforGGHEtoreach5.0%ofGDPby2030.TheReportalsourgesadditionalinvestmentonhealthpromotionprogrammes,regulationof user fees in the private sector, implementation of aMedical Insurance Scheme in the civilservice,increasingtheallowablereliefsforincometaxpurposesforpeoplehavingprivatehealthinsurancepoliciesandconductinganationalsurveyontheextentofcatastrophicexpenditureonhealth.

Examining multiple funding flows to public healthcare facilities in Kenya and their influence on provider behavior and service delivery

RahabMbau,EvelynKabia,Dr.EdwineBarasaKemri-WellcomeTrust,KenyaNairobi

Introduction:Healthcareprovidersoftenengagewithmultiplepurchasers resulting inmultiplefundingflows.Wheremultiplefundingflowsexist,theymaysendsignalstoprovidersthatmayincentivize undesired provider behavior.We examined the characteristics of multiple fundingflowstopublichospitalsinKenyaandhowtheyinfluenceproviderbehaviorandservicedelivery.

Methods:Weconductedacross-sectionalqualitativestudyintwofirstreferralandtwosecondreferral public hospitals, purposively selected from two counties in Kenya. We employed aconceptual framework that theorized that a lackof coherenceofmultiple funding flows couldleadtothreetypesofundesiredproviderbehavior; resourceshifting,patientshifting,andcostshifting.Wecollecteddatausingin-depthinterviews(n=36),focusgroupdiscussions(n=4),anddocumentsreview,andanalyzedthemusingaframeworkapproach.

Results:Thestudyhospitalsexperienced10identifiablefundingflowsacrosstherangeoftheirfundingsources.Multiplefundingflowsimprovedthefinancialresilienceofhealthcarefacilitiesby improving the levelof resourcingandoverallpredictabilityof facility financing.HigherNHIFpayment rates for outpatient services for civil servants compared to non-civil servants and,higherNHIFpaymentrates for inpatientservices forall itsbeneficiariescomparedtouser feesled to shifting of resources to provide preferential services to civil servants or in other cases,insuredpatientsingeneral.Forinstance,somefacilitiesestablishedspecialcivilservants’clinics


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andwardswhileothershadamenitywardsforallinsuredpatientsthatwerebetterstaffedandequipped than the general wards and clinics for the uninsured patients. There was alsodiscriminatorybehavior in somehospitals. For instance, civil servantswerepermitted to jumpqueues (andhencehadshorterwaiting times)whileotherpatientswaited tobeservedat thehealthcarefacility. Incaseofdrugstockouts,civilservantswereassuredofgettingmedicationthroughthehospital’sarrangementswithprivatepharmacieswhileotherpatientshadtobuythedrugsthemselves.TherelativepredictabilityofNHIFpaymentscomparedtouserfeepaymentsincentivized health facilities to facilitate the NHIF enrollment of patients needing expensiveelectivesurgicalproceduresorlong-terminpatientcare.

Conclusion: Multiple funding flows can improve the financial flows of healthcare facilities.However, if not structured coherently, they could incentivize undesired behavior that couldcompromise health system goals. For instance, the shifting of resources and discriminatorybehaviorofthestudyhospitalsislikelytoresultininequityinaccessandcompromisedqualityofcare. There is a need to structuremultiple funding flows coherently to avoid these undesiredoutcomes.

Healthcare financing in Nigeria: A systematic review assessing the evidence of the impact of health insurance on primary health care delivery

YakubuAgada-Amade,UniversityofNigeria,EnuguCampus,NationalHealthInsuranceScheme,Abuja

Strengthening health systems, improving health outcomes, as well as finding answers to thecompetingalternativesofhealthcarefinancingarecritical issuesthatcontinuetobotherhealthpolicymakers. Irrespective of the options, the choice of health care financing shouldmobilizeresources forhealthand improveaccess toquality careat the same time.Notably, thehealthfinancingpolicyinNigeriaprovidesaframeworkforestablishinghealthinsuranceschemessoasto expand coverage in health care delivery for the formal and informal sectors as a strategytowards universal access to healthcare. Accordingly, the authors, through this review,systematicallyassesstheevidenceoftheextenttowhichhealthinsuranceimpactsonaccesstoservices and quality of primary health care in Nigeria.While this comes to bear, the findingsrevealanevidenceofmoderate-to-highstrengththathealth insuranceincreasesaccesstocareandimprovesthequalityofcarereceived;however,itremainsequivocalinsomeinstances.Thereview, therefore, contributes to the literature on health care financing by extending andqualifyingexistingknowledgeandadvocating foracceleratedreforms ifuniversalcoveragewillbeachieved.

Is there any Fiscal Space for Health? Lessons learnt from resource mapping exercise in Malawi

HenryMphwanthe1PakwanjaTwea2HenryMphwanthe1KateLangwe2Malema3PakwanjaTwea21HealthPolicyPlus2MinistryofHealthandPopulation-Malawi3OptionsConsultancyServicesLimited-UK

Background:Theprovisionofhealthequitableandqualityprimaryhealthcareservicesislargelydependent on the availability of adequate financial resources. However, planning andcoordinationofhealthactivitieshasbeenachallengeinMalawiduetothesubstantialoff-budgetdonor funding. To address this challenge, the Government ofMalawi has adopted an annualresource mapping exercise to track health sector resources and to inform planning andbudgetingdecisionsbothfortheMinistryofHealthanditsdevelopmentpartners.TheMinistry


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of health has also been exploring a ways of increasing the fiscal space for health throughinnovating health financing mechanisms. However, evidence from a recent sector wide fiscalspace analysis shows that the country has limited fiscal space for additional resources for thehealthsectorandonlypointsatefficiencyastheonlypossibleroutetoincreasingthefiscalspacefor health. The recent resourcemapping exercise showcases the areaswhere these efficiencygainstopotentiallyberealized.

ThisTHEpercapitaamount is significantly lower than theWHOrecommendedamountof$86percapita.ThissituationiscompoundedbythefactthatMalawiisheavilydependentondonoraid,accordingtotheNHA2015,externalpartnerscontribute62%oftheTHE.Inlightofthis,thecountry has been exploring mechanisms for generating additional domestic revenue. TheMinistry of Health developed a proposal for generating additional domestic resources to theMinistryofFinance.However,Thirdly,

Objective:Toexplorehowresourcemappingandtrackinginformationcanbeusedtoenhanceresourceallocationefficiency, technicalefficiency,and improvepredictabilityandeffectivenessofdonorfinancingforhealthinMalawi.

Methodology: The study used Resource Mapping round 5 data to understudy whether thecompared to theHSSP II strategicprioritiesandcosts toquantify the fundinggap,analyze thefunding gap by programmatic areas to identify areas of duplicative funding, overfunding, andunderfundingtoinformhighlevelresourceallocationandreprogrammingdecisions.

Findings:DespitehavingoneofthehighestTotalHealthExpenditures(THE)asa%oftheGDPintheSADCregion,at$40,MalawihasthelowestTHEpercapita.

Conclusion: The prospects for additional funding for health in Malawi are bleak. However,Resource mapping and tracking can be used to identify opportunities for efficiencies andgenerate additional fiscal space for health. This will help to ensure that health resources aregoingtowardsaddressingpopulationhealthneeds.

What are the health financing needs of mobile populations in East Africa? The case of long distance truck drivers in East Africa

AgnesGatome,AbtAssociatesKenyaNairobi

Background: Landlocked countries Burundi, Rwanda, Uganda, South Sudan of the East AfricaCommunity (EAC) rely on the trucking industry through Kenya and Tanzania for imports andexports.Longdistancetruckdrivers(LDTD)spendlongperiodsontheroadandawayfromhome,whichtendstocomewithcertainhealthriskssuchasabuseofalcoholandotherstimulants,andhigh risk sexual activity. This study sought to understand LDTD’s mobility characteristics,healthcareneedsandmeansforpayingforhealthcarewhileonworkrelatedtravel,andabilityandwillingnesstopayforaportablehealthinsuranceproductthatwouldcoverhealthexpensesacrossallEACcountriesduringworktravel.

Methods: USAID funded Cross-Border Health Integrated Partnerships Project conducted 361LDTD interviews, as part of a larger study, betweenNovember 2016 and February 2017 fromthree cross-border areas: Malaba Kenya-Malaba Uganda, Holili Tanzania-Taveta Kenya, andGatuna Rwanda-Katuna Uganda. LDTD were recruited while in transit at cross-border towns.DatawasanalyzedwithSTATA togeneratedescriptive statisticsandmultivariatemodelswereusedtoestimatethe impactofvarious individual level factorsonabilityandwillingnesstopayforportablehealthinsurance.

Results:LDTDreported20-30workrelatedtripsinthepastyearwithamediandurationofoneto twoweeks. 19.1% reported using a health facility while on theirmost recent work trip of


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whomhalfreportedexpensesoutsidetheirhomecountry.85.5%ofLDTDreportedpayingout-of-pocket(OOP)forhealthexpensesincurredduringworktravel.OOPexpenseswereashighas40%ofmonthlyincome.42.4%ofrespondentsreportedowninghealthinsurancebutonly16.3%withhealthinsurancereporteditcouldbeusedbeyondtheirhomecountry(portablebenefits).75% of respondents agreed a portable health insurance product was relevant to their healthneeds. Average household income varied between USD 120-415 across cross-border areas.54.9% of respondents stated they were willing to pay USD 9.2 (2.6% of the lowest monthlyincomereported)quarterlyforportablehealthbenefitsofwhom52%agreedtheywerewillingtopaythehigherpriceofUSD11.5(3.2%ofthelowestmonthlyincomereported).

Discussion: These results demonstrate that LDTD are highly mobile, require access to healthservicesoutsidetheirhomecountry, facehighOOPcosts,andarecurrentlyunderservedwithportablehealth insurance.Asnextsteps, theresultswillbedisseminatedtopublicandprivateinsurerswithintheregiontoinformdesignofportablehealthinsuranceformobilepopulations.

Does Predictability of Multiple Funding Flows to Healthcare Facilities influence Provider behaviour? Lessons from Case studies in Enugu State Nigeria.

IfeyinwaArize1,3,4,ChinyereMbachu2,3,ChinyereOkeke2,3,ObinnaOnwujekwe1,31DepartmentofHealthAdministrationandManagement,FacultyofHealthSciences&Technology,CollegeofMedicine,UniversityofNigeriaNsukka,EnuguCampus2DepartmentofCommunityMedicine,InstituteofPublicHealth,CollegeofMedicine,UniversityofNigeriaNsukka,EnuguCampus.3HealthPolicyResearchGroup,4DepartmentofPharmacologyandTherapeutics,CollegeofMedicine,UniversityofNigeriaNsukka,EnuguCampus.

Background:AchievingUniversalHealthCoverage(UHC)requiresthathealthsystemsmustseekways to ensure that health services are efficient, equitable and with universal financial riskprotection. It is also important that appropriate services are strategically purchased to ensurethatUHCisachieved.Hence, it isnecessarythatfundflowsfrompurchaserstoprovidersmustalignwiththeinterestsofallmajoractorsinthehealthsystem.

Objective: To examine the predictability of the different funding flows available to publichealthcareprovidersandhowpredictabilityoftheflowsinfluencesservicedelivery.

Methods: The study was conducted in Enugu State, Southeast Nigeria.We employed a crosssectional study design and qualitative method (Key Informant Interviews (KII), Focus Groupdiscussion(FGD))incollectingdataforthestudy.Purposivesamplingoftwopublictertiaryandsecondaryhealth facilitieseach,purchasers, centralAdministrators,developmentpartnersandcivilsocietyorganizationswasadopted.DatawerecollectedthroughKII(n=108)ofpurchasers,FGD(n=64)ofhospitalclients.

Findings:ThestudyfoundthatthesourcesoffundingtothepublichealthfacilitiesweremultipleandareOOP,governmentbudget,healthinsuranceanddonations.Noneofthedifferentfundingflowswaspredictable.However,OOPwasconsideredthemostpredictableandmostcommonsourceoffundingforthefacilitiesbecausemostpatientspayingout-of-pocketpaytheirbills,andonlyafewdelayinpayingtheirbills.FindingsshowedthatHMOsdelaypaymentsofcapitationand reimbursement of fee for service, hence NHIS funding is unpredictable. Consequently,unpredictabilityoffundstohealthfacilitiesresultsinpoorplanninganddecisionmaking.Italsoleadstopreferenceforcertainservicesandwasfoundtoaffectqualityofservicedeliveryas itlimitstherangeofservicesthefacilitiescanprovide.However,unpredictabilityoffundswasnotfoundtoresultinpreferenceforcertainpatientgroupsfortreatmentasfrontlinehealthworkers


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are unaware of the patients' healthcare purchasing mechanism. In order to cope withunpredictabilityoffundsthefacilitiescomeupwithdifferentcopingmechanismssuchaslimitingdrugsavailableforNHISpatients.

Conclusion:Predictabilityoffundstohealthcareproviderssendssignalsthatinfluenceproviderbehaviour as it influences effective service delivery. It results in poor planning and decisionmaking as facilities are handicapped. Consequently, it has quality of healthcare services andefficiency implications posing a serious challenge in achieving universal health coverage inNigeria.

Out-of-pocket healthcare payment in the era of national health insurance: A five-year study of primary health facilities in seven districts of northern Ghana.

EdmundWedamKanmikiAyagaA.Bawah,PatrickAsuming,CaesarAgula,JohnKokuAwoonor-Williams,JamesF.PhillipsandJamesAkaziliRegionalInstituteforPopulationStudies,UniversityofGhana Background: Ghana introduced a national health insurance program in 2004with the goal ofremovingtheimpoverishingeffectsofout-of-pockethealthcarepaymentsandensureaccesstoequitablehealthcare.However,overadecadeofimplementation,theimpactofthisprogramonout-of-pocketpayments is inconsistent. Thispaper contributes tounderstanding the impactofGhana’sinsuranceprogramonout-of-pockethealthcarepayments.

Aimsandobjectives:Toexaminethe impactofGhana’snationalhealth insuranceprogramonout-of-pockethealthcarepaymentforprimaryhealthcareusinghealthfacility-baseddata.

Methods: Using a five-year panel data of revenues accruing to public primary health facilitiescollectedby theGhanaEssentialHealth InterventionProject (GEHIP), descriptive statistics andtrendanalysisareemployedtoexaminerevenuesaccruingfromout-of-pocketpaymentvis-à-vishealthinsuranceclaimsforhealthservices,medicationandobstetriccare.

KeyFindings:Out-of-pocketpaymentforhealthservicesandmedicationswerefoundtoreduceby 63% and 62% respectively between 2010 and 2014. Insurance claims for services andmedication however increased by 37% and 34% respectively in 2013 and by 13% and 9%respectivelyin2014.Obstetriccarewasentirelycoveredbyinsuranceclaimswhichincreasedby92% and 75% for 2013 and 2014. Thus, the revenue base of primary health outlets isprogressivelyshiftingfromout-of-pocketpaymenttoinsuranceclaims.

Conclusion: The evidence implies Ghana’s national health insurance program is significantlycontributing to reducing out-of-pocket payment for primary healthcare, thereby reducingfinancialbarrierstoaccessinghealthcare.Effortstoensurethesustainabilityofthispolicyareintherightdirection.

Parallel Session 4-2 Maternal and child health care 1 Health demographics and trends in child and youth health indicators in Ivory Coast from 2012 to 2016

Sackou-Kouakou Julie-Ghislaine, Centre for Population Health Research and Health Systems / InstitutNationalofPublicHealth(INSP)-Abidjan,IvoryCoastKouaméJérôme,AdouPhilippeAgenor,PongathiéAdama,MaléFélix,KouadioLuc


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Justification: Health human resources contribute to improving access to health services andhealthindicators, includingchildandyouthhealthindicators.Toimprovehealthdemographics,IvoryCoasthasadoptedseveralstrategies,includingtheregionalizationofpostssince2014.

Objective: To analyse the correlations between health demographic indicators, and child andyouthhealthindicatorsover2012-2016period.

Methodology:RetrospectivestudyofannualreportsonthehealthsituationinIvoryCoast.Thehuman resources forhealth (HHR) indicatorswerephysician/population,nurse/populationandmidwifery/womeninreproductiveage(WRA)ratios.Childandyouthhealthindicatorsweretheincidence of diarrhoea, acute respiratory infections (ARIs), malaria and malnutrition. Theevolutionofthemedianoftheindicatorshasbeendescribed.TheHHRstandardwascomparedtoWHO standards. The Pearson correlation coefficient was used tomeasure the relationshipbetween the two groups of indicators. We have chosen to consider r values not includedbetween-0.5and0.5.

Results: The median incidences of child/youth morbidity indicators increased from 293‰ to558‰ for malaria, from 68.32 ‰ to 95.24‰ for diarrhoea and from 6‰ to 9.43‰ formalnutrition. Themedian incidenceof ARI increasedby about 50% from2012 to 2015beforedecliningin2016(174‰).Themedianpopulation/physicianratiosimprovedbutremainedbelowthe WHO standard of 1 doctor per 10,000 population. The median population-to-nurse andmidwife ratios improved from2013 to2016, from1nurseper4262 inhabitants to1per3069andfrom1midwifeper2213FAPto1per1616,respectively.Exceptforthecorrelationbetweenthe midwifery/WRA ratio and the incidence of malnutrition in 2012, which was 0.70, thecorrelations between the HHR ratio and child/youthmorbidity indicators weremostly < -0.5.Thus,thedoctor/populationcorrelationandtheincidenceofARIsincreasedfrom2012to2013(-0.52to-0.69)andthenstabilizeduntil2016.Theratiobetweenthenurse/populationratioandmalaria incidence was -0.62 in 2012 and -0.68 in 2014. The correlation between themidwifery/WRAratioandtheincidenceofdiarrhoeawas-0.61in2012.

Conclusion: These results could reflect a problem in the quality ofmanagement of childhooddiseasesbythehumanresources.

Community Walls of Good Health: Community-led monitoring and advocacy tools to improve maternal and child health outcomes in rural Ghana

Mohammed Ali1, John Koku Awoonor-Williams2, Felicien Paul Randriamanantenasoa1, Elena McEwan1,AdamAbdul-Fatahi1andAbubakariAbdulGaniuKonlan11CatholicReliefServices2GhanaHealthServices

Background In the year 2000, Ghana Health Service (GHS) adopted its flagship CommunityHealthPlanningandServices(CHPS)concept.Withcommunityengagementasakeycomponent,theCHPsinitiativeutilizedparticipatorytoolstomonitorandadvocateforimprovedhealthwithafocusonmaternalandchildhealth(MCH)outcomes.CatholicReliefServices(CRS)andtheGHSin collaboration with target communities implemented the CommunityWalls of Good Health(COWAH)strategy. COWAHisusedinCHPSaspartofthecommunitydecisionsystem.Ineachcommunity, a five-member committee rallies and empowers communitymembers to supportMCHdatacollectionforplanninganddecision-makingpurposes.ItalsoprovidesmechanismsforthesecommunitiestoadvocateforqualityMCHserviceandavailability.


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MethodsCRScarriedoutabaseline(October2011)andendlinesurvey(September2015)in240communities to measure change in MCH outcomes where the COWAH, a participatorycommunity-ledmonitoringandadvocacytoolfromtheCHPSinitiativewereused.

Results Skilled assisted deliveries increased from 30% to 88% (p =0.002); Initiation ofbreastfeedingincreasedfrom48%to75%(p<0.001);exclusivebreastfeedingimprovedfrom47%to92%-p>0.001;proportionof children(6-23months) fedonappropriate complementary foodsincreasedfrom55%to98%:P<0.000);proportionofchildren(0-23months)withdiarrheawhoreceived ORS/home fluids increased from 42% to 66%; p =0.005). Also, the COWAH conceptcontributedtoreductioninmaternalmortalityfrom258to81per100,000livebirthsaswellasunder five and infantmortality reduced from98and72per1000 livebirths respectively to26and 32 per 1000 livebirths respectively. Among children 0-23months, stunting rates reducedfrom17%to13%,p>0.001;underweight reduced from43%to11%andwasting reduced from26%to8%;p<0.001.

ConclusionsCOWAHstrategycontributedto improvedcommunityownershipandengagementforprimaryhealthcareprovisionandutilization.Also,COWAHappearspromisingas it impactspositivelyonMCHoutcomes.Additionally,COWAHwasfoundtostrengthencommunityhealthsystems as it served as a participatory community-led monitoring and advocacy tool. Thestrategy has since been adopted by some districts in its northern and upper east regions ofGhanaaswellasotherCRSCountryprogramsincludingBurkinaFasoandNiger.COWAHhasthepotentialofcontributingtoachievingSustainableDevelopmentGoals2and3.

An Evaluation of the Maternal and Child Health Project of the Subsidy Reinvestment and Empowerment Programme (SURE P)

Ifeanyi Nsofor,IkeAnya,ChikweIhekweazu:ABUJAEpiAFRIC

Background: Access and utilization of quality health care services by women and children inNigeriaremainspoor.TheGovernmentofNigeriapartiallyremovedpetroleumsubsidiesin2013and used savings to set up an intervention programmebetween to address this. Fundsweredirectedtoincreasingandimprovinginfrastructureandhumanresourcesinprimarycareaswellasimprovingdemandthroughtheuseofincentives,primarily“ConditionalCashTransfer(CCT)”at1000healthfacilitiesacrossNigeria.

AimsandObjectives:Theaimof theevaluationwas toassess theextent towhichtheSUREPMCH Project was meeting objectives, provide recommendations to guide the remainingimplementationperiodoftheprojectandprofferrecommendationsforthepost-2015period.

Methods: This evaluation was carried out using both quantitative and qualitative methods.Trendanalysiswascarriedouttoevaluatethe impactofthe interventiononrelevanttrends inutilization measures. Qualitative methods consisted of key informants’ interviews and focusgroupsdiscussionswithstakeholders.

Results: The post implementation period showed improvement in most variables of interest,includinga36.3%increaseinnumberofpregnantwomen’santenatalcarevisits.Wefoundthatfacilities with CCT component only performed better with respect to two of the six variablesevaluated: newborns provided with OPV at birth and newborns provided with BCG at birth.Qualitativeanalysisshowedimprovedperceptionofqualityofcareininterventionfacilitiesandalackofconfidenceinactivitiesinvolvingthetransferofcashincentives.

Main Conclusions: The programme led to an improvement in the utilization indicators andconfidenceoftheusers inthesystem.Itwouldpossiblyhaveachievedgreatersuccess if ithadbeenmore independent. The project raised the question on whether a vertical intervention


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addressingaspecificindicatorisappropriateorwhetherabroaderstrengtheningoftheprimaryhealthcaresystemisabetterapproach.

Preferences of pregnant women attending antenatal care regarding prevention of mother-to-child HIV transmission service delivery models in Ethiopia: Discrete Choice Experiment

EliasAsfaw1,JosueMbonigaba2,MikeStrauss3,SylviaKaye41University of California Davis (MINIMOD Project) and The Children Investment Fund Foundation (SUREProgram),AddisAbaba,Ethiopia2UniversityofKwaZuluNatal,EconomicsDepartment,Durban,SouthAfrica3UniversityofKwaZuluNatal,HealthEconomicsandHIV/AIDSResearchDivision,Durban,SouthAfrica4DurbanUniversityofTechnology,PublicadministrationandEconomicsdepartment,Durban,SouthAfricaBackground:Thepreventionofmother-to-childtransmission(PMTCT)programisavitalpartofthe HIV response, but low PMTCT service uptake remains a critical challenge in Ethiopia.Understanding the demand-side factors that drive low service uptake is necessary to informeffortstoincreasedemandandofferclient-centeredservices.

Objective: This study aims to analyze the preferences and drivers of choice regarding PMTCTservicedeliverymodels.

Methods:Atotalof275pregnantwomenattendingantenatalcareacrosstwelvehealthfacilitieswere randomly sampled to be interviewed using a discrete choice experiment (DCE)method.Participants were asked to choose between two service delivery models that included sixattributes(pre-testcounseling,serviceintegration,disclosurecounseling,waitingtime,cost,andPMTCT site location). Each participant responded to 64 choice sets,whichwere generated tomaximizeD-efficiency.Aconditionalrandomeffectlogiteconometricmodelwasemployed.

Findings:Couplepre-testcounselingwaspreferredoverindividualpre-testcounseling(OR1.23,p=0.000).Apregnantwomanwaitingfor1hourand2hourswaslesslikelytopreferthePMTCTservice, respectively as compared to waiting for 30 minutes (OR 0.75, p=0.001; OR 0.76,p=0.000).Therespondentspreferrednottopayfortheservices(USD1.27,USD2.54).Pregnantwomen preferred PMTCT services at the health center as compared to health post (OR 1.26,p=0.001).Theoddsofchoosingcouplepre-testcounselingbyapregnantwomanfromtheruralareas was lower as compared to the urban respondent (OR 0.77, p=0.003). Urban pregnantwomen were less likely to prefer waiting for longer time period (OR 0.72, p=0.72, p=0.04).PregnantwomanfromtheruralsettingswerelesswillingtopayUSD2.54forthePMTCTservice(OR0.52,p=0.000),andmorewillingtoreceiveapaymentUSD5.08(OR2.09,p=0.000).

Conclusion: Pretest counseling, waiting time, fees and location were the critical attributesaffecting the preferences of pregnant women. The preferences of urban and rural pregnantwomanvaried inthePMTCTserviceattributesofservice integration,waitingtime,servicefeesand location. HIV programs should prioritize meeting client needs on these attributes andconsiderdifferentmodelsbasedonlocation.


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Parallel Session 4-3 Result and performance based financing

Towards a constructive reflection on Performance-Based Financing: perspectives of implementing actors in Sub-Saharan Africa

SergeMayakaMD,Phd,Economistedelasanté,EcoledesantépubliquedeKinshasaLara Tembey, Eric Bigirimana, Christophe Y Dossouvi, Olivier Basenya, Elizabeth Mago, PacifiqueMushagalusaSalongo,AloysZongo,FanenVerinumbe

Background information:AnendlessandfruitlessdebatearoundPerformance-BasedFinancing(PBF)isbecomingincreasinglypresentamongexpertsengagedinhealthsystemsstrengthening,butwithoutcontributingtoabetterhealthstatusofourpopulations.AsexpertsdirectlyinvolvedintheimplementationofthePBF,webelieveitisusefultoshareourperspective.

Goals:Tobepartof theofcontrol’s renewalof thedebatesaroundthePBFandthereturntomoreimportantandtechnicalfoundations;butalso,searchingforevidence-basedconsensus.

Researchobjectives:(1)ReflectontheevolutionofthePBFapproach,particularlyinourworkingcountries, (2) highlight its benefits in our health systems and the transformations observed inhealth, and (3) examine the challenges and propose orientations for reforming itsimplementation.

Methods used:Documentary reviewand interviewswithactors involved in implementation indifferentAfricancountries

Key findings: The PBF has some advantages but we recognize that challenges need to becontinuously improved, and that critical debates andanalyses constituteopenings toquestiononeself;

• Constructivedebatesmustbeevidence-based;valuethewiderangeofexperiencesandrequire all parties to listen objectively to the arguments of stakeholders, particularlythosewithlocalknowledgeanddiverseinstitutionalaffiliations;

• ThePBFwaslaunchedinRwanda,andwerecognizethatinourcountriesitbenefitsfromthe financial and technical leadership of the World Bank and other external actors.Exogeneitycanbeaproblembuttoofarfromaxiomatic.

• ThePBFisanevolvingstrategy,characterizedbyseveralinnovationsandchangesmadebynationalactorsintheircontext.

• WeseethevalueofthePBFin itssystem-wideeffects,suchas improvedcoordination,accountabilityfordecentralizationandoverallgovernanceofthesystem,aswellasthecompletenessandtimelinessofthehealthinformationsystemdata.

Mainconclusions:Withoutcomplacency,ourmainconcernshouldbetostrengthenourhealthsystemsforthebenefitofthepopulation.WearecommittedtoplayinganimportantrolebothatthenationalandgloballeveltocontinuouslyupdatethePBFapproachaswelearnfromit.

Performance-based Financing and External Cross-Audit: a tool improving the governance approach in DR Congo

SergeMayakaMD,Phd,Economistedelasanté,EcoledesantépubliquedeKinshasaRobertYao,MichelZabiti,XavierLannuzel


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Background information: As part of the implementation of its PBF program in the DRC, theWorldBankhascontractedwithanExternalCounterAuditAgency(ACVE)toconductquarterlycounter-audits. ACVE's mission is to confirm or deny the veracity of verified, validated andremunerated quantitative and qualitative data, aswell as compliancewith procedures, in theprovincesoftheDRCunderPBFprogram.

Aims:Byhighlightingthedifferencesbetweentheresultsoftheauditandthecross-checkinginthePBF,thisworkanalysesthe indicatorsofusingserviceandqualityofcareofthesubsidizedentities,theirperformancemeasurementandwaysofimprovingtasksoftheauditors.

Researchobjectives:

• Cross-check the performance frameworks of regulatory entities and contracting and auditagencies;

• Cross-checkthereliabilityquantitativeandqualitativedatainselectedhealthfacilities;andatcommunitylevel;

• Identifypossibleover/underperformanceevaluations;• Suggestappropriatesolutionstoaddressidentifiedissues.

Methodology:Datacollectiontoolsandmethodsshouldbefullyconsistentwiththeaudittools.Arandom(stratified)andreasonedsamplingwasusedtoselecttheentitiestobecross-checked,except for the control and audit agencies and the automatically selected zone managementteams.

Keyfindings:Mostofthestructures(zonemanagementteams,healthcentres,HGR,)thatwerecross-checked presented, on average, higher evaluation results than those of the cross-check.Thereasonsforthedifferencesobservedare:problemswiththedocumentationorreportingofcertain documents, or even poor archiving with the absence of certain files ; follow-up ofactivities and implementation of recommendations; misunderstanding or interpretation ofvalidation criteria, with some non-objective validations. These over declarations haveconsequencesintermsoffinanciallossesorlostprofitsfortheWorldBank(WB).

Main conclusions: We could claim that the principles of the PBF are applied rigorously andobjectively in thevariousprovinces financedby theWB,butwith limitations in someof them.Theproperperformanceofexternalcross-checkingmissionscouldstrengthenthemonitoringofhealthsectorperformanceandthe improvementofgovernanceofthesector. Itcontributestotheapproachofaperfectiblefinancingapproach.

Health Sector Application of Programme Based Budgeting – Early Lessons from Kenya

BenjaminTsofa,1*ProtusMusotsi1,SassyMolyneux,1,2,EdwineBarasa1,ThomasMaina3,JaneChuma31KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast,Kenya2CentreforTropicalMedicineandGlobalHealth,NuffieldDepartmentofMedicine,UniversityofOxford3TheWorldBankGroup,KenyaCountryOffice-Kenya Introduction: Health sector planning and budgeting is a governance process linking long-termstrategies with daily operations and financial allocation. Kenya adopted a Medium-TermExpenditureFramework (MTEF)andAnnualWorkPlans (AWPs) toalignpublic sectorplanningand budgeting process, but misalignment has continued to be witnessed; both in the healthsectorandpublicsectormorewidely.APublicFinanceManagementAct(PFMA)wasadoptedin2012 to guide the planning and budgeting process, which introduced Programme BasedBudgeting (PBB) replacing the traditional line item budgeting. PBB aimed at better linking of


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priority technical programmes identified during planning, with budgetary allocation, and atincreased accountability, transparency and openness. There is limited knowledge on theapplicationandutilityofPBB inthehealthsector inLowandMiddle-IncomeCountries(LMICs)andthisstudysoughttoaddressthisgapinknowledge.

Methodology:WecarriedoutasystematicsearchandreviewofliteraturethathasdocumentedhealthsectorapplicationandutilityofPBBinLMICs.Wethensortouttocollectempiricaldatatoexamine the experience of PBB in health sector planning and budgeting at County level. Wereviewed all relevant policy and guidelines document that guide the planning and budgetingprocessinthecountry.Wethenconducted28in-depthinterviewswithindividualsnationallevelkeyinformantsfromtheMinistryofHealth,CouncilofGovernorsSecretariatanddonoragenciessupportinghealthsectorplanningandbudgetingprocess.Wethenconductedxxinterviewswithindividuals involved in county level health sector planning and budgeting in six purposefullyselectedcounties.WeappliedtheWaltandGilsonpolicyanalysistriangletoguidedevelopmentofdatacollectiontoolsanddataanalysis.Weappliedathematicapproachfordataanalysis.

Results:TheCountylevelhealthsectorAnnualWorkPlan(AWP)developmentforfinancialyear2017/18 utilised the PBB. However, with no proper guidelines on the process, there was avariation across counties on the numbers and definitions of ‘programmes’ identified forallocationofresources.Theplanningprocesswasperceivedtohaveimprovedthealignmentoftechnical priorities with budgetary allocation; and increased transparency, accountability,opennessoftheprocess.However,PBBimplementationwasfacingchallengesbecauseoflackofclear tools and guidelines, low capacity at county level, political interference, and that theIntegrated Financial Management Information System (IFMIS) used for public sector financialmanagementwasstillorganisedaroundlineItems.

Conclusion:PBBispotentiallyausefultoolforaligninghealthsectorplanningandbudgeting,andmaking the AWP result-oriented. However, realization of this would be enhanced by thedevelopedofcleartoolsguidelines;andbuildingcapacityforcountyhealthsectormanagers;andreformingtheIFMISbudgetarymanagementsystemtoalignitwiththePBB

Understanding the contextual and implementation factors constraining the results of a Performance Based Financing scheme extended to malnutrition in Health centers of Burundi— insights from a mixed method research in Burundi

*ManasséNimpagaritse,**CatherineKorachais***JeanMacq,**BrunoMeessen:*Bujumbura Institut National de Santé Publique, ** Institute of Tropical Medicine, ***UniversitéCatholiquedeLouvain

Background: There is a growing interest within the scientific community for the channelsthroughwhichPBFschemesdelivertheireffects(ornot)athealthfacilitylevel.Moreover,it isincreasingly acknowledgedwithin the Performance-Based Financing (PBF) research communitythatPBFismorethanjustpaymentsbasedonoutputsverifiedforquality.Infact,PBFschemesareimplementedina‘complexadaptivesystem’).Thecontext,thus,becomesaninherentpartofeachPBFschemeandincludesimportantdriversofchangethat influencetheoutcomesandtheprocesses/mechanismsthatarebeinginitiated.

We used the opportunity of the introduction of malnutrition prevention and care indicatorswithin the PBF program in Burundi to advance our understanding of contextual andimplementationfactorsthatinfluencedthecourseoftheinterventionandtheoutcomes.

Method: This study builds on the program theory of the intervention and a mixed methodsmodeladoptingasequentialexplanatorydesign.Thequantitativecomponentmainlyexploitsa


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largesetofresearchinstrumentsappliedtothe90healthcentresoftheimpactevaluation.Thequalitativecomponentmainly restson logbooks filled inweekly inhealthcentresand in-depthinterviewswithkeyinformantsfromasubsetof12healthcentres.

Results: SixcontextualfactorswereidentifiedtohavecontributedtothelimitedresultsofthenutritionPBFintervention:Paymentissuesofsubsidiestohealthfacilities/Healthworkers,lackof autonomy at health facilities level, communication /information problems on the newintervention,skillsofhealthworkers,resourcesnonavailability,andnoimprovedsupervision.

Conclusion:Theinterventionwasconstrainedbyhealthsystemfactorsaswell.ThePBFattemptstopromoteproblemsolvingattheperipheral level,butthis levelremainsconstrainedbymoresystemicelements.Thisconfirmsthattheperformanceofahealthsystemisalongstruggle.

Using the Performance Based Financing (PBF) conditional grants to increase domestic resource allocation to health sector within the Kenyan context of devolution.

ConsolataOggot,OmarAhmed:NairobiMinistryofHealth

Background: The health status of Kenya’s population has improved over the last decade.However,considerable inequitystillpersistswithwidevariation inhealthstatusbygeographicand socioeconomic factors. One of the barriers to access and utilization of health services isinadequateandinequitablehealthcarefinancing.In2014,Kenya’seconomywasrebasedandisnowalower-middle-incomecountry.Thus,theneedforthemobilizationofdomesticresources.Kenya embarked on rapid devolution process to 47 counties. Subsequently, two-thirds ofgovernmenthealthcareallocationsweredevolvedtocounties,accountingforabout30%ofthecountysharablerevenue.TheKenyangovernmentissupportingthe47countiestoimprovethedelivery, utilization, and quality of (Primary Health Care) PHC services at the county level byusingPBFthatemploysminimumconditionsandallocationofresourcestothecountiesbasedontheir improved PHC results. The four key indicators used to measure performance are- fullyImmunizedchild,fourthantenatalcare,skilledbirthattendanceandfamilyplanningcoverage.

Objectives: To assess compliance of the counties in attaining the minimum condition of theshareof the countybudgetallocation forhealth ishigher than theprevious year,butnot lessthan 20% and the Public Finance Management (PFM) criteria and verify the 47 countiesimprovedPHCresults.

Methodology:DataforthedescriptiveassessmentwasobtainedfromMinistryofHealth,Kenyacounty health budgets and the District Health Information System-2 for the period April-June2017andApril-June2018.SPSSwasusedforstatisticalanalysis.

Results:94%countiescompliedwiththePFMcriteria.72%countiesmettheminimumconditionofcountybudgetaryallocation tohealth;28%of thecountiesdidnotmeet thecriteriadue toreduction incapital investments in thecurrent financialyear.94%of thecountieshadpositivePHC result improved; 19% of the counties have an average result improved greater than 20.Overall,only72%countieswereabletoattainboththepositive improvedPHCresultsandthetwominimumconditionsconcurrently.

Conclusion:ThePBFisaneffectivepolicytoolinaddressingincreasedcountydomesticresourceallocationtohealthsector.Theapplicationoftheminimumconditionsatcountylevelshavealsoimproved PFM and accountability and ownership of PHC results at county. However, otherfactors that influence performance (access and utilization of health services) within healthsector-political, and social-economic. Thus there is need to consider these factors in the PBFallocationtocounties.


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PBF in Sierra Leone: The Way Forward

PuravaJoshi,MinistryofHealthandSanitation,SierraLeone Background: In 2011 and 2015, Sierra Leone implemented Performance Based FinancingSchemes(PBF)withtheaimofpayinghealthfacilitiesbasedontheirperformanceonmaternalandchildhealth indicators.Anevaluationof theScheme2foundthatthePBFwassuccessful inincreasing provider autonomy, but its potential was dampened by delayed payments, andinaccurateexternalverifications.TorectifythepastissueswiththePBF,theMinistryofHealthinSierraLeoneisre-designingthePBFandwillpilotitintwodistrictsthisyear.

Aim:

• ToconductabottleneckanalysisofthepreviousPBF,toidentifytheexactcausesof itsconstraintsandtherebyofferrecommendationsforthenewPBF.

• To recommend ways in which the PBF – a form of strategic purchasing – can beintegratedwiththerestofthehealthsystemofSierraLeone,andthewiderenvironmentofprovider-purchaserarrangements(i.e.,“notmissingtheforestforthetrees”)3.

Methods: The research will be primarily based on interviews with a variety of stakeholdersinvolved in the previous PBFs – national and local Ministry of Health staff, district healthmanagementteams,localcouncils,healthfacilityworkers,anddonoragencies.TheauthorsareeconomistsattheMinistryofHealth,andareinauniquepositiontoaccessdataandanecdotesfrom stakeholders. Two of the authors were involved in the implementation of the first twoPBFs.Findings fromtheevaluationof thePBFconductedbyCordAidwillalsocomplementourresearch.

Initial findings: Initial findings show thatbefore thePBFcanbe implemented, certain systemsneedtobestrengthened:(i)Datareporting:Accuratedataiscrucial,asprovidersarepaidonitsbasis. Therefore, certain systems are required to be in place – staff trained in data entry,technologyforenteringanduploadingdata,etc.(ii)Publicfinancialmanagement:ThepreviousPBFssawfacilitiesreceivingtheirmoneyaftermorethanayear.TheresearchwillproposePFMmeasures toaddress this, andalsoexaminehow to integrate the ‘output-based’payments forthePBF,withthepaymentsfortherestofthehealthsysteminSierraLeone,whicharetypicallyinput-based.

Using the Performance Based Financing (PBF) conditional grants to increase domestic resource allocation to health sector within the Kenyan context of devolution.

ConsolataOggot,OmarAhmed:NairobiMinistryofHealth

Background: The health status of Kenya’s population has improved over the last decade.However,considerable inequitystillpersistswithwidevariation inhealthstatusbygeographicand socioeconomic factors. One of the barriers to access and utilization of health services isinadequateandinequitablehealthcarefinancing.In2014,Kenya’seconomywasrebasedandis

2 CordAid (2014). Performance Based Financing in Healthcare in Sierra Leone. External Verification – Final Report. In: Freetown and the Hague: Cordaid, vol. 1 3 Soucat, A., Dale, E., Mathauer, I., & Kutzin, J. (2017). Pay-for-performance debate: not seeing the forest for the trees. Health Systems & Reform, 3(2), 74-79.


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nowalower-middle-incomecountry.Thus,theneedforthemobilizationofdomesticresources.Kenya embarked on rapid devolution process to 47 counties. Subsequently, two-thirds ofgovernmenthealthcareallocationsweredevolvedtocounties,accountingforabout30%ofthecountysharablerevenue.TheKenyangovernmentissupportingthe47countiestoimprovethedelivery, utilization, and quality of (Primary Health Care) PHC services at the county level byusingPBFthatemploysminimumconditionsandallocationofresourcestothecountiesbasedontheir improved PHC results. The four key indicators used to measure performance are- fullyImmunizedchild,fourthantenatalcare,skilledbirthattendanceandfamilyplanningcoverage.

Objectives: To assess compliance of the counties in attaining the minimum condition of theshareof the countybudgetallocation forhealth ishigher than theprevious year,butnot lessthan 20% and the Public Finance Management (PFM) criteria and verify the 47 countiesimprovedPHCresults.

Methodology:DataforthedescriptiveassessmentwasobtainedfromMinistryofHealth,Kenyacounty health budgets and the District Health Information System-2 for the period April-June2017andApril-June2018.SPSSwasusedforstatisticalanalysis.

Results:94%countiescompliedwiththePFMcriteria.72%countiesmettheminimumconditionofcountybudgetaryallocation tohealth;28%of thecountiesdidnotmeet thecriteriadue toreduction incapital investments in thecurrent financialyear.94%of thecountieshadpositivePHC result improved;19% of the counties have an average result improved greater than 20.Overall,only72%countieswereabletoattainboththepositive improvedPHCresultsandthetwominimumconditionsconcurrently.

Conclusion:ThePBFisaneffectivepolicytoolinaddressingincreasedcountydomesticresourceallocationtohealthsector.Theapplicationoftheminimumconditionsatcountylevelshavealsoimproved PFM and accountability and ownership of PHC results at county. However, otherfactors that influence performance (access and utilization of health services) within healthsector-political, and social-economic. Thus there is need to consider these factors in the PBFallocationtocounties.

Parallel Session 4-4 Purchasing of services

Analysis of the mixed system of payment terms and conditions for service providers in the context of the strategic procurement of health services in Burkina Faso

JoëlArthurKiendrébéogo,UniversityofOuagaPr.JosephKi-Zerbo,InstituteofTropicalMedicine(IMT),Anvers,Belgium,UniversityofHeidelbergFahdiDkhimi,Technicalofficer,HealthFinancingTeam,WHO,GenevaOlivierAppaix,independentConsultant,France&USA Introduction:Thereliablereformedhealthfinancingfortheprocurementfunctionisapowerfullever for transforming health system andmaking progress towards universal health coverage(UHC).Nowadays,thereisawide-rangingconsensustomovefromaso-calledpassiveapproachto procurement health services (no selection of providers, performancemonitoring, efforts toinfluenceprices,quantityorqualityofcare)toanactiveorstrategicapproach.Tobecomemorestrategic, theprocurement functionmustcreateacoherentsetof incentives toaligncaregiverbehaviourwithUHCobjectives.


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Objectives:Thegeneralobjectiveofthestudywastounderstandthemixedsystemofpaymentmethods in place in Burkina Faso, the combination of incentives created on the behaviour ofprovidersatthedecentralizedlevel,aswellasthechallengesintermsofgovernance.

Methodology:Naturally,thestudywasqualitative.DatacollectiontookplacefromFebruarytoApril 2017. It consisted of a documentary review (scientific and grey literature) and semi-directive interviewsat thecentralandperipheral levelsof thehealthsystem.Amonograph, inconsiderationoftwohealthdistricts,wascarriedoutinordertoclarifypaymentchannelsandtonotetheeffectsobservedwithserviceproviders.Thechoicewasmadeonthesetwodistrictsforthey have been the subject of various experiences over many years with the procurementfunctionofservices.

Results:Thestudyproposedamappingthathighlightedamultiplicityofinstitutionalpurchasersofcareaswellasproviders fromwhomtheypurchaseservices throughoneormorepaymentmethods. This multiplicity adds complexity to the system and, sometimes, hinders theachievementoftheinitialobjectivesthatprevailedwhenoneortheotherpaymentmethodwasintroduced.Moreover,itisaggravatedbyadynamicofongoingreformsandgovernance-relatedissuessuchas the lowautonomyofhealth facilities, the lackofpredictabilityand regularityofpaymentsorfrequentdrugshortages.

Conclusion: This study clarified the situation of the payment mix of healthcare providers inBurkinaFasoandidentifiedsomeoftheeffectsthatcanbeattributedtoit,inordertofeedintothenationaldialogueonstrategicpurchasingasaleverforprogresstowardstheUHC.

Attribute development and level selection for a choice experiment on capitation and fee-for-service mechanisms

MelvinObadha1,JaneChuma1,2,JacobKazungu1,andEdwineBarasa1,31HealthEconomicsResearchUnit,KEMRI|WellcomeTrustResearchProgramme,Nairobi,Kenya.2TheWorldBankGroup,KenyaCountryOffice,Nairobi,Kenya.3NuffieldDepartmentofMedicine,UniversityofOxford,Oxford,UnitedKingdom

Background: The use of stated preference elicitation methods such as discrete choiceexperiments (DCEs) have been gaining ground in the field of health economics. However, thevalidityofDCEshasbeencriticised.OneofthemainaspectsthataffectsthevalidityofDCEs istheprocessusedtodevelopattributesandselect levels.Researchershavebeenvagueonhowattributes and levels for their DCEs havewere developed. This has been due to the lack of astandardisedprocessinattributedevelopmentandlevelselection.Tobridgethisgap,wesetouttodocument theprocess followed inderivingattributesandselecting levels foraDCE toelicitthepreferencesofhealthcareprovidersfortheattributesofproviderpaymentmechanisms inKenya.

Methods:We used a four-stage process proposed by Helter and Boehler to report the stepsfollowed in attribute development and level selection. The steps include; raw data collection,data reduction, removing inappropriate attributes, and wording of attributes. Raw data wascollectedbyconductingaliteraturereviewandaqualitativestudythatentailedsemi-structuredinterviewswith29managementteammembersinsixhealthfacilities.

Results: The literature reviewunearthedsevencharacteristicsof capitationand fee-for-servicethatinfluencedhealthcareproviderbehaviournamely;paymentrate,adequacyofthepaymentrate to cover the cost of services, timeliness of payments, payment schedule, performancerequirements, and complexity of accountability mechanisms. The qualitative study reinforcedthe literature review results by identifying five attributes that providers considered important


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namely;thepredictabilityofthetimingofpaymentdisbursements,thepredictabilityofamountsdisbursed, the adequacy of the payment rate to cover the cost of services, complexity andburdenofreportingandclaimsmechanisms,andautonomyoverresources.Thereafter,datawasreduced,classified,andsummarised.Then, inappropriateattributeswere removedconsideringcriteriasuchassalience,plausibility,andcapabilityofbeingtraded.Finally,theattributeswerewordedappropriatelywhichresultedinfiveattributes.Theseattributeswerepretestedinpilotstudywith31 respondents. Four attributesmade it to the finalDCE. These included;paymentschedule,timelinessofpayments,paymentrate,and,servicescovered(benefitspackage).

Conclusion: Rigorously reporting the process of attribute development and level selectionincreases the validity of discrete choice experiments in health economics. Researchers andchoicemodellersinallsettingsshouldalwaysreporttheprocessusedtoderivetheirattributes.

Health care purchasing in Kenya: experiences of health care providers with capitation and fee-for-service provider payment mechanisms

MelvinObadha1,JaneChuma1,2,JacobKazungu1,andEdwineBarasa1,31HealthEconomicsResearchUnit,KEMRI|WellcomeTrustResearchProgramme,Nairobi,Kenya.2TheWorldBankGroup,KenyaCountryOffice,Nairobi,Kenya.3NuffieldDepartmentofMedicine,UniversityofOxford,Oxford,UnitedKingdom

Background:Providerpaymentmechanismsplayacriticalroleinuniversalhealthcoveragedueto the incentives they create forhealth careproviders todeliverneeded services,quality, andefficiency.Therefore,whendesigningproviderpaymentmechanisms,understandingproviders’experienceswith-andpreferences for- thecharacteristicsof thesepaymentmethods isuseful.For this reason, we set out to explore public, private, and faith-based health care providers’experienceswithtwocommonproviderpaymentmechanismsinKenya;capitationandfee-for-service.Indoingso,weaimedatidentifyingtheattributesofproviderpaymentmechanismsthatprovidersconsideredimportant.

Methods:Weconductedaqualitativestudy in twocounties inKenyabetweenSeptemberandDecember2017.Datawascollectedusingsemi-structuredinterviewswith29managementteammembers in six health providers (two private, two faith-based and two public providers)accreditedbytheNationalHospitalInsuranceFund(NHIF).Aframeworkapproachwasappliedindataanalysis.

Results:Providershadagoodunderstandingofcapitationandfee-for-servicepaymentmethodsand how they worked. Capitation and fee-for-service payments from the NHIF and privateinsurers were reported as good revenue sources as they contributed to providers’ overallincome. The expected fee-for-service payment amounts from NHIF and private insurers werepredictable while capitation funds from NHIF were not because the providers did not haveinformationonthenumberofenrolees in theircapitationpool.Moreover,capitationpaymentrates were perceived as inadequate to the cover costs of services provided. Additionally,capitationandfee-for-servicepaymentsfromNHIFandprivateinsurersweredisbursedlateandNHIF’sreportingrequirementsforfee-for-servicepaymentswasperceivedascomplex,whichledtomonetarylossestohealthcareproviders.Finally,publicprovidershadlosttheirautonomytoaccessandutilisecapitationandfee-for-servicefundsfromtheNHIF.

Conclusion: Through their experiences, public, private, and faith-based health care providersrevealedcharacteristicsofproviderpaymentmechanismsthattheyconsideredimportant.Theseinclude theextent towhichproviderpaymentmechanisms contributed to theoverall revenueenvelope, the predictability of the timing of payment disbursements, the predictability of


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amountsdisbursed,theadequacyofthepaymentratetocoverthecostofservices,complexityandburdenofreportingandclaimsmechanisms,andautonomyoverresources. Considering these characteristics in the design of provider payment mechanisms while alsoinvolving health care providers in the process is a crucial step towards improving quality,efficiency,andcoverageofneededservices.

A critical analysis of healthcare purchasing arrangements in Kenya: A case study of the county departments of health.

RahabMbau,EvelynKabia,EdwineBarasa:Kemri-WellcomeTrust,Nairobi

Background: Purchasing in healthcare financing refers to the transfer of pooled funds tohealthcareprovidersfortheprovisionofhealthcareservices.Thereislimitedempiricalworkonpurchasing arrangements and what is required for strategic purchasing in low and middle-incomecountries.Weconducted this study tocriticallyassess thepurchasingarrangementsofthecountydepartmentsofhealth(CDOH)whoarethelargestpurchasersofhealthcareinKenya.

Methods:We employed a qualitative case study approach to assess the extent to which thepurchasingactionsof theCDOH inKenyawerestrategic.Wepurposivelysampled10counties,and collected data using in-depth interviews (n=81), focus group discussions (n= 4) anddocumentsreview.Weanalyzeddatausingaframeworkapproach.

Results:Countydepartmentsofhealthdidnotpracticestrategicpurchasing.Thegovernment’s(nationalandcounty) roleasa steward for thepurchasing functionwascharacterizedbypooraccountability and inadequate budgetary allocations for service delivery. The absence of apurchaser-provider split between the CDOH and public healthcare providers underminedprovider selectionbasedonperformanceandquality.Poorpublicparticipationand ineffectivecomplaints and feedbackmechanisms limited public accountability and responsiveness to theneedsofthepeople.

Conclusion: Our findings show that while there are frameworks that could promote strategicpurchasing of the CDOH, strategic purchasing is impaired by poor implementation of theseframeworks and the inherentweaknesses of a public integrated purchasing system that lackspurchaser-providersplit.

Strategic procurement of basic health care: what role for planned demand (mutual health insurance) in the UHC process in Comoros?

*NailatBahati,**PascalNdiaye,*MohamedBacar:*NationalFederationofMutualHealthInsuranceCompaniesofComoros,**TechnicalAdvisorofInternationalDevelopmentandResearchCentre Background: Like most African countries, Comoros has been committed to Universal HealthCoverage(UHC)since2017.Oneof thecoveragemechanismsconsidered inthestrategy is themutualhealthinsuranceschemesthatdevelopedwiththeCommunitymodel,intheComorosinthe1990s.Gradually,3mutualunionsweresetupandthenanationalfederation(FENAMUSAC).Thenetworkcurrentlycoversnearly32,944beneficiaries.AJointManagementService(SCG)towhich mutual delegate health risk management, provider relations and governance capacitybuilding, has been established. Institutionally, the SCG, composed of professionals, ensuresqualitytechnicalmanagement.IthasbeenincludedinthePBFschemeinComoros,tofulfilthefunctionofcarebuyer.


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Methodology: This is a 5-year retrospective study.We compared 6 health indicators: serviceutilization rate, particularly for curative consultations, which are essential care; use of ANCservices;andassistedchildbirth.

Results: Between 2013 and 2017, the total amount allocated to the PBF program was € 2.5million.Aproportionof90%wasusedfortheprocurementofcareand10%forintermediationcosts.Intermsoftechnicalresults,thefollowingchangeswereobserved:

• Animprovementintheuseofcurativeserviceswhichis15.15%significantlyhigherthanthenationalaverageof14.6%;

• An improvement inpregnancy follow-up, thecoverage rate inANC3 is50.73%withanincreasing use of ANC services. The approach has helped to build pregnantwomen'sloyalty to the use of ANC services, with a steady increase in the number of ANC4 by1.83%;

• Anincreaseintherateofassistedchildbirthfrom72%in2013to85%in2017.

Another observed effect is the increase in the intermediation capacity of the SCG,whichwasabletorecruit3additionalprofessionals.

Conclusion The networking of mutual health insurance can have an impact on the strategicprocurement of basic health services. The technical control of disease risk and experience incontracting constitute an added value for the UHC edifice. In addition, this approach is aresponsetotheproblemofthefinancialviabilityof intermediationstructuresformutualandastrengthening of their negotiating power with the provision of care (because they have aprocuring functionwith incentives).Thisexperience isa realcontributionto thearticulationofhealth insuranceandhealthsystemperformancefromaUHCperspective,withtargetedactionontheprovisionofcare.

Impact of the RBF approach on the technical viability of mutual health insurance - focus on streamlining care

TARTOUDJIBEWatade1,DJIMRAMADJIArmand2,NDIAYEPascal3

Introduction:FinancialaccesstohealthcareisstillanidealforalargepartoftheChadians.Theestablishment (in 2010) of a network of seven mutual districts (MDs) aims to meet thischallenge.LikemostmutualhealthinsurancecompaniesinAfrica,thoseinChadgiveprioritytoprimary care at a medium cost (MC) estimated at CFA F 2,500, in the health centres (HC).However, after a few years of implementation of the Program, there has been a persistentincreaseincarecosts.

Objective:Toanalysetheeffectofthefinancialincentiveforprovidersonstreamliningcareandthefinancialviabilityofmutual,abouttheCMofbenefits.

Methodology: The effect was analysed over the period (2014-2018), in an MD (Danamadji)covering16HC,andselectedforitshighMClevel.Rationalrequirementsarethosethatcomplywiththenational flow-chart in forcewhichdeterminestheircost.This indicatorwascombinedwiththreeothers(penetrationrate,promptnessandcompleteness)toformtheMutualResultsBasedFinancing(RBF-M)package.

Results:Thestudyrevealednon-rationalizationasoneofthemaincausesofsoaringcosts.TheintroductionoftheFBR-MmadeitpossibletosignificantlyreducethecumulativeMCsintheHCon study. Theother indicators (penetration rate, promptness and completeness) alsodeclinedover the same period. On average, MCs fell by 32% with disparities between HCs (2.79% to


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40.95%). MCs for the treatment of recurrent diseases such as malaria and acute respiratoryinfectionsdecreasedby29%and23% respectively.Overall, the introductionof theRBF-Mhasmade it possible to significantly improve themutual health insurance company's performanceindicators.

Conclusion: The results obtained suggest that the RBF-M influences the cost of services andprescription for a basic package. It also demonstrates that rationalization of care is a criticaldeterminantof theviabilityof insurancemechanisms likeHM.Thisprovisionalconclusion is tobeendorsedbycountries thatare implementing theUHCandholdRBFprograms.However, itdeserves more comparative investigation to establish more correlation of cause and effect(scoringmethod).ThesemutualareshowingthemselvesasagatewaytoreachtheUHC.

Strategic purchasing in healthcare in Kenya: Examining reforms by the National Hospital Insurance Fund

RahabMbau,EvelynKabia,EdwineBarasa:Kemri-WellcomeTrust,Nairobi

Introduction: Kenya has prioritized the attainment of universal health coverage through theexpansionofhealthinsurancecoveragebytheNationalHospitalInsuranceFund(NHIF).In2015,the NHIF introduced reforms in premium contribution rates, benefit package, and providerpaymentmechanisms.

Objective: To examine the influence of the NHIF reforms on NHIF’s purchasing practices andtheir implications for strategic purchasing and health system goals of equity, efficiency andquality.

Methods:WeconductedanembeddedcasestudywiththeNHIFasthecaseandthereformsasembeddedunitsofanalysis.Wecollecteddataatthenationalandcountylevelthroughin-depthinterviewswithpurposivelyselectedhealthfinancingstakeholdersand,publicandprivatefacilitymanagersandfrontlineproviders(n=41),focusgroupdiscussions(n=4),anddocumentsreview.Weanalyzedthedatausingaframeworkapproach.

Results: Our findings show that even with the new reforms, the NHIF remains a passivepurchaserwithpotential negative implicationsonequity, efficiencyandqualityof care. Equitywascompromisedby:1) limitedawarenessofthenewbenefitsandunaffordabilityofthenewpremiums for certain population groups (rural, poor, elderly, people with disabilities,unemployed and informal sectorworkers), 2) Differences in the benefit package between thenational scheme and civil servants scheme whereby members of national scheme lackedpreventive services and other curative services, 3) Pro-urban and pro-private distribution ofcontractedhealthfacilitieswhichhinderedaccessforthoseinruralandmarginalisedareasandlastly,4)Delayedreimbursementsandlowercapitationratesfortheoutpatientservicesforthenational scheme which led to discrimination of national schememembers in favour of otherpatients(civilservants,privately insuredand/oruninsuredcash-payingpatients)particularly inprivate hospitals. Efficiencywas compromised byweak accountabilitymechanisms that led toresourcelossthroughunnecessarytreatmentproceduresandfraudulentclaims.Qualityofcarewas compromised by poor monitoring of quality of services, poor infrastructural capacity ofpublichospitals,andrationingofservicesduetoperceivedlowreimbursementrates.

Conclusion: In pursuit of universal health coverage, reforms should focus on strengtheningstrategicpurchasingactionsthatareaimedatimprovingequity,efficiency,andqualityofhealthservicedelivery.


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Parallel Session 4-5 User fees - removal and exemptions

Co-existence of High Out of Pocket payments for health and free health care in public health facilities a paradox for consolidating primary health care in Mauritius.

MrAjoyNundoochan,WorldHealthOrganization,CountryOffice,Mauritius,DrLaurentMusango,WorldHealthOrganization,WHORepresentative,CountryOffice,MauritiusMrYusufThorabally MrSooneerazMonohur,MinistryofHealthandQualityofLife,Mauritius

Background:Mauritius isembracingwelfarestateprinciplessincefourdecadesandanycitizenindistinctlyiseligibleforfreehealthcareinpublichealthfacilities, includingtertiaryspecialisedcare. Paradoxically, a new trend has emerged recently with Household Out of Pocket (OOP)expenditureonhealthoutweighingGeneralGovernmentHealthExpenditure (GGHE).ThismayhinderprogressmadetilldatetostrengthenPrimaryHealthCare(PHC) forachievingUniversalHealthCoverage(UHC).

Objectives: This paper analyses trends in OOP and its impact on key indicators of financialprotection i.e. Catastrophic Health Expenditure (CHE) and impoverishment due toOOP healthexpenditure.Thestudy,also,determinebenefitdistributionofhealthcare, intermsofpro-richorpro-poor.

Methods: Using multiple Household Budget Surveys, incidence of CHE is estimated using thecapacity to pay and the budget share standard approach. Impoverishment due to OOP ismeasured by changes in incidence of poverty and severity of poverty based on the US$ 3.1internationalpoverty line.Tocarryout thebenefit incidenceanalysisa four -stageapproach isimplemented, starting with ranking household using expenditure variables followed byestimating utilization rates of day care services for each household,multiplying the utilizationrateofhealthservices,andaggregatingbenefitsofutilizationexpressedinmonetaryterms,foreachhousehold.Thedistributionofhealthbenefitsacrossincomequintilesisestimatedusingaconcentrationindex.

Findings:Adeclining trend inCHEand impoverishmentover the ten-yearperiod in the lowestquintile isconfirmed.Conversely, forother incomequintilesCHE increasedacrossall thethreethresholds(10%,25%and40%)from2001to2012.The incidenceofCHE ismoresignificant inurbanareapromptingadichotomybetweenurbanand rural regardingequityofaccesshealthservices. Households pushed below the poverty line due to OOP spending dropped from0.0848%to0.054%overtheten-yearperiod.In2012,onlyhouseholdsclassifiedunderQuintile1(0.244%)andQuintile2(0.025%)weredriftedunderthepovertylineduetoOOPexpenditureonhealth.Concentration index forall incomequintileswas0.12, inferringhealthcarepoliciesarepro-poororientedandpromotesfinancialprotection.Thequalityofcare inpublicserviceswasnotassessedinthisstudy.

Conclusion: Progress towards UHC can be accelerated through expansion of the fiscal space.Existing conducivemacroeconomic fundamentals favourpotential expansion throughwideningoftaxbase,improveduseandperformanceofpublicresourcesaswellasassessingthequalityofcareinpublichealthservices.TaxesonTobaccoandAlcoholrepresent80%ofGGHE.However,institutingearmarkingtaxesmayleadtofungibilityandreprioritizationwithinthehealthsectorratherthanbetweenhealthandothersectors.


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Aligning public financial management system and free healthcare policies: lessons from a free maternal and child healthcare programme in Nigeria

OgbuaborDaniel,InstituteofPublicHealth,UniversityofNigeriaNsukkaOnwujekweObinna

Background:Despitethatpublicfinancialmanagement(PFM)systemcaninfluencehowhealthfinancingpoliciescontributetouniversalhealthcoverage,relativelylittleisknownabouthowtoalignPFMandfinancingofuniversalcoverageschemesinlow-andmiddle-incomecountries.InEnuguState,decliningnumberofhealthfacilitiesreimbursedforfreematernalandchildhealth(MCH) services, persistingout-of-pocketpayment forMCH services and inadequate fundingoffree maternal and child health programme (FMCHP) suggest that PFM and health financingfunctionsaremisaligned.

Aims and objectives: The paper assessed the alignment of PFM systemwith health financingfunctionsintheFMCHPofEnuguState,Nigeria,andprovidesevidenceofhowPFMcanbebetteralignedwithFMCHPobjectives.

Methods:Datawerecollectedthroughdocumentreview(policydocumentsandadministrativeand financial records) and semi-structured interview with 16 purposefully selected state anddistrict-levelpolicymakers(n=16).Qualitativedatawereanalysedusingaframeworkapproachguided by Cashing and colleagues’ framework for assessing the alignment of public financialmanagement(PFM)andhealthfinancingpolicies.Weconductedrevenueandexpendituretrendanalysis using descriptive statistics (means, standard deviations and graphs) and analysis ofvariance(ANOVA).Levelofsignificancewassetatρ<0.05.

Findings: The results showed that no more than 50% of the promised fund were collectedbetween2010and2016despitesignificantincreasesinthepopulationoftargetbeneficiaries(ρ<0.05).Levelofpoolingwaslimitedbyrecurrentunauthorisedexpenditure(averaging34%perannumover7years)andabsenceofexpenditurecaps.Misalignmentofbudgetmonitoringandpurchasing includedelays in provider payment (range: 1-15months), high administrative cost,poor financial information disclosure and absence of auditing. Whereas the drug costssignificantly declined from 86% in 2013 to 38% in 2016 (ρ < 0.05); the cost of servicessignificantlyincreasedfrom10%in2013to43%in2016(ρ<0.05).Yet,theadministrativecostofpurchasingsignificantlyrosefrom4%in2013to19%in2016(ρ<0.05).

Conclusions: There is a need for evidence-informed annual budget, compliance with healthfinancingrules,clarityofrolesandresponsibilitiesforvariousFMCHPcommittees,disclosureoffinancialinformation,useofclearresourceallocationstrategyandtimelypaymentofproviders.These strategies would ensure efficient and effective use of public funds to finance freehealthcarepoliciesinlow-resourcesettings.

Cost implications free maternal policies: Lessons from both the globe and implementation in Kenya

BonifaceOyugi,SallyKendall,OlenaNizalova0,StephenPeckhamCentreforHealthServicesStudies(CHSS),RutherfordAnnex,UniversityofKent,Canterbury,CT27NX,UKUniversityofNairobi,SchoolofPublicHealth,HealthSystemManagement,Nairobi,Kenya Background: There are nearly 290,000 maternal deaths due to preventable pregnancy andchildbirth related complications globally. Low- and middle-income countries are the mostaffected because of poor access to and utilization of maternal and family planning services.


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Several countries, including Kenya, are addressing the challenge by reducing catastrophicexpenditure onmaternity care through incentives such as free (non-user fee) delivery (birth)policieswithaviewtoachievingUHC.

Objectives: To explore the cost implications of the global free maternal policies (FMP) andevaluatethecostofthefreematernityimplementedinKenya

Methods:Anongoingstudy thatusesmixedmethods. Inpartone,wesystematicallysearchedthroughEBSCOHost,ArticleFirst,CCRCT,EmeraldInsight,JSTOR,andPUBMEDdatabasesguidedby the preferred reporting item for systematic review and meta-analysis protocol (PRISMA)guideline.Atotalof43papersmetthecriteriaandtheirthemeswereanalysedthematically.Parttwo, isanembeddedcasestudydone in3countyhospitals inKenyathatwilluseastructuredquestionnaire to collect cost data from postnatal mothers and health workers from October2018tillFebruary2019.

Results: Review findings showed that households, in different countrieswere still bearing theburden of out of pocket (OOP) payments, and some experienced catastrophic expenditures,despitetheimplementationofFMPs.Majorityofthereviewedpolicieswereunsustainabledueto poor planning or haphazard implementation of the policies and some governments wereresorting to more domestic tax or grants from donors. Additionally, the review evidencedinequalityofaccessandutilisationofFMPsbetweentherichandpoorhouseholdsparticularlyinrural areas. We anticipate having results from Kenya during the conference to build on thereview.

Conclusion:Many FMSwere formulated on the premise of reducingmaternalmortalities andcateringforpregnantmotherswithaviewtoachievingUHC.TheresultsfromtheKenyancasestudy and the reviewwill be used to contribute to the current discourse on Universal HealthCoverage(UHC)andhelpimprovetheKenyaFMP.Thepoliciescanreducethefinancialburdenon the households if well implemented and sustainably funded. In addition, they may alsocontribute to decline in inequity between the rich and poor though innovation and strategiccollaborationwithpartners.Additionally,thereisaneedtopromoteawarenessofthepolicytothe poor and disadvantaged women in rural areas to help narrow the inequality gap onutilisationandreduceimpoverishmentofhouseholds.

Factors explaining catastrophic health spending in Côte d'Ivoire

C.JulianaF.Gnamon,FelixHouphouetBoignyUniversityofCocody,Côted’Ivoire

As inmanylowandmiddle incomecountriesplaguedbyhighpovertyrates,healthspending isessentially financed by private spending in Cote d’Ivoire, Out of pocket spending being theessential part of those. In the context of the institution of a national scheme for healthinsurance, it is of interest to analyse incidence of catastrophic spending and investigate itsdeterminants.

Thisstudyusesdifferentthresholdsincludingacompositeonetoprovideadescriptiveevidenceof catastrophic spending and a logit model to estimate the determining factors of thephenomenon. Data comes from a nationally representative secondary source of a LivingStandardsMeasurementSurveyof2014.

Resultssuggestthathealthspendingisverylowforpoorhouseholds.Acertainnumberofsocio-economicfactorsprovedtoberelatedtocatastrophicspending.Largehouseholdsize,locationinurban areas and higher level of income appeared to protect households from incurringcatastrophic health spending. Having a household head who is male, employed and haveattained university also reduced the odds of suffering from catastrophic health spending.


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Utilization of formal care (outpatient and inpatient) and existence of health shocks are otherdeterminingfactors.

Access to health care is a three-tiermarket in the country. Very poor households skip use ofhealthcareincaseofneed,avoidingtoincurspending.Householdswhodaretousehealthcarewithout insurance are at tremendous risk of incurring catastrophic health spending. Richerhouseholdusehealthinsurancetoprotectthemselvesagainstthephenomenon.Healthsystemsreformsshouldaimtoextendprepaymentmechanismsand increase financialprotection.Theyshouldalso target vulnerablepopulationandensureprogressive contributions soas to reducethecurrentfragmentationofhealthcaremarketandinequitiesinaccess.

Effect Of Public Health Expenditure On Catastrophic Health Expenditure In Sub-Saharan Africa

AlbertOpokuFrimpong,UniversityofProfessionalStudies,Accra,Ghana

Thebasicfunctionofhealthsystemstowardsachievinguniversalhealthcoverageistoimprovehealth outcome and prevent financial catastrophe due to payment for health services. Theavailable evidence indicates that larger proportion of households in sub-Saharan Africa incurcatastrophic health expenditures. Therefore, how public policy influences the risk of and exitfromcatastrophichealthspending isamootpoint toconsider.There isextensive literatureonthe relationshipbetweenpublichealthexpenditureandhealthoutcome.However,howpublichealthexpenditure influences theriskofandexit timefromcatastrophichealthexpenditure isrelativelyscarce,especiallyonsub-SaharanAfrica,andthisstudytookthisupbyexploringdataon 45 sub-Saharan countries for the 1995-2014period, sourced from theWorldBank’sWorldDevelopment Indicators. The analyses employed the 5 percent catastrophe threshold ofhouseholdstotalexpenditure,1.27percentgrowthrateofout-of-pockethealthexpenditure,andthepopulationaveragegeneralisedestimatingequationregressionmodel.Thestudyfoundtheaverageexittimefromcatastrophetobe2.58years.Also,theresultsshowedthatout-of-pockethealthspendinghaspositive,immediate,andlargereffectswhereaspublichealthspendinghasnegative, delayed, and smaller effects on risk of and exit time from catastrophic healthexpenditures.Theresultsagainrevealedthatwhenahouseholdisfacedwithcatastrophichealthexpenditure, a unit increase (decrease) in out-of-pocket health expenditure as percentage ofhousehold’s income increases (decreases) the exit time by 3.41 years whiles a unit increase(decrease) inpublichealthexpenditurereduces(increases)thecurrentexittimeby1.12years.This study, therefore, concludes that exit time from catastrophe is less responsive to publichealth spending than to out-of-pocket health spending. As regards, a more proactive publicpolicyoption is,perhaps, to influence thegrowth rateofout-of-pockethealthexpenditureviaprovisionofprimaryhealthservicestoprevententryintocatastrophichealthexpenditureamonghouseholds.

Keywords:Catastrophichealthexpenditure,publichealthexpenditure,exittime

Equity in Out of Pocket Health Care Expenditure in Turkey: An Analysis of 2004 – 2013 Years

RasiCeyhan,AnkaraMinistryofHealth

Healthfinancingcanbedefinedasmeansofcreationofresourcesnecessarytocoverhealthcarecosts.Aimofhealthcarefinancingistocreatesufficientandsustainableresourcestoensureallindividualstoaccesshealthcare.Therearealsootheraimsthatareproductiveuseofresources,


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insurance of equity in finance while providing financial protection for all, and protection ofhouseholdsagainstpovertywithmeansofcreationofresources.

Equity in health means absence of systematic differences among groups who have differentlevelsofsocialadvantagedanddisadvantaged,andmajorsocialdeterminantsofhealth.Equityinhealthfinancingmeansthatindividualsmakecontributionstohealthcarefinancinginproportionwith their financialpower.Verticalequity inhealth financingmeans that individualswhohavedifferent levels of income contributehealth financingdifferently, andhorizontal equitymeansthat individuals who have the same level of income contribute health financing the sameamount.

Inthisstudy,verticalequityinoutofpockethealthexpendituresof2004–2013yearsinTurkeywas researched. Data of 2004 – 2013 Household Budget Surveys done by Turkish StatisticalInstitutewereused.DescriptivestatisticswereheldbyanalysingdatawithSPSS.Concentrationindexes, Gini coefficients and Kakwani indexes were produced by analysing data with STATA.Research period of this study includes implementation of Health Transformation Programmethat changed Turkish Health System substantially, and transition years of Universal HealthInsurance.

Outofpockethealthexpenditures inTurkeyareregressivefrom2004to2013years.There is-0,01increaseinregressivityfrom2004(Kakwaniindexis-0,31)to2013(Kakwaniindexis-0,32).FromHealth Transformation Programme implementation in 2003 that changed TurkishHealthSystemsubstantiallytotransitiontoGeneralHealthInsurancein2010,andafterthreeyearsofthis,equityinoutofpockethealthexpenditurescouldn’tbeensured.

Themost important improvement inequity inoutofpocketexpenditures isafter twoyearsofHealth Transformation Programme implementation (Kakwani index is -0,29 in 2005). Then, anincreaseinregressivityinoutofpocketexpendituresisseenduetoeffectsofeconomiccrisisinthe World. There is an improvement again in equity in out of pocket expenditures due totransitiontoGeneralHealth Insurancetroughoutthecountryafter2010.Asaresult,equity inout of pocket expenditures in Turkey for the years of 2004 – 2013 remained regressive andverticalequitycouldn’tbeensured.

Parallel Session 4-6 Evaluating PHC performance 1

Assessment of the operational capacity of first contact health institutions in the management of malaria in Côte d'Ivoire

HounsaAnnita,MelessDavid,SangaréAboudramane,PongathieAdama,SambaMamadou,KouadioLucDepartmentofPublicHealth,HydrologyandToxicology,FacultyofPharmaceuticalandBiologicalSciences,Félix Houphouët-Boigny University, Ivory Coast, Department of Public Health, UFR Odontostomatologie,Félix Houphouët-Boigny University, Ivory Coast, Directorate of Information and Sanitary Informatics,MinistryofHealthandPublicHygiene,IvoryCoast Introduction: In 2017, 80% of malaria deaths worldwide were concentrated in 18 countries,including Côte d'Ivoire. Early diagnosis and correct treatment are the backbone of malariamanagement.However,dohealth facilities (ES),especially thoseat theentranceof thehealthsystem, have the basic resources for themanagement ofmalaria cases? The objective of ourstudywastoanalyzetheOperationalCapacity(CO)ofIvorianfirst-contactESinthemanagementofmalaria.


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MaterialandMethods:TheServiceAvailabilityandReadinessAssessment(SARA)methodologywasusedtocarryoutadescriptivecross-sectionalstudyfromJuly10thto30th,2016.TheOCforthe management of malaria expresses the average availability of 9 indicators divided into 3domains: (i) Staff anddirectives; (ii) diagnostic capability; (iii) drugs andproducts. A scoreperdomainwascalculatedbasedonthenumberofelementspresentineachdomain.ThisscorebydomainandCOwerecomparedbetweenthefirstcontactESaccordingtothemanagementbody(public/private)andthezone(urban/rural)usingtheChi2testforariskofthefirstspeciesαfixedat0.05.

Results: A total of 963 ESwere selected including 818 of first contact including 651 from thepublicsectorand167fromtheprivatesector;331locatedinurbanareasand487inruralareas.Staffavailabilityandguidelines,diagnosticcapacity,drugsandproductswerehigherinthepublic(75%,93%and85%respectively) than in theprivate sector (40%,71%and53%).Thiswas thesameinruralareas(77%,92%and87%)comparedtotheurbanarea(54%,82%and67%).TheOC formalaria treatmentwas alsohigher in thepublic than in theprivate sector 81%against49%,andinruralareascomparedtotheurbanarea83%against63%.

Conclusion:Thefirst-linepublicandruralESshadthebasicresourcesformalariamanagementincontrasttotheirhighmortality.ThereisaneedtofocusonthemalariatreatmentprocessattheleveloffirstcontactHEs,strengtheningthehealthsystemasawholeinadditiontoprevention.

KeyWords:IvoryCoast.Operationalcapacity.Healthinstitutionsoffirstcontact.Malaria.

Universal Health Coverage Primary Health Care Self-Assessment in Sudan

MohammedMustafa,MinistèreFédéraldelasanté

The study identified practical policy opportunities in the health system to improve the rela-tionshipbetweenhealth financingandPHCefforts inSudan. IthasassessedhowpublichealthfinancinginstitutionsandhealthinsuranceinteractwithotherPHCactorsandprograms.Also,ithasidentifiedkeyareasofimprovementandopportunitiestoalignhealthfinancingpolicymakersinthecountrywithPHCgoals.

Theassessmentwasarapiddescriptivecross-sectionalmixedmethodstudyincludingqualitativeand quantitative methods. It covers national level and selected six states. The respondentsrepresented Ministry of Health, Ministry of Finance, National Health Insurance Fund andprovidersofservicesatbothprivateandpublicfacilities.

ThereisaconsensusamongallinterviewedpolicymakersontheimportanceofPHCtoachieveUHC.PHCseenas thebasiccomponentofhealthsystemthat includecomprehensiveessentialservices packagedirected towards all population age groups. Lack ofwell-trainedhealth staff,insufficient fundingand lowservicesqualityarethemainbarriers toachievePHCobjectives inSudan.

Themainsourceofhealthsystemfunding inSudan isdirectOOP,whichhasreached79.4%oftotalhealthexpenditurein20154.Mostofthoseexpenditureswereexertedoncurativecareatsecondary and tertiary level.Nevertheless, thepatients have topayuser fees forMost of thecurative services provided at PHC level.Most of the respondents agreed that fundswere notenoughtocoverallPHCservicescomponents.Available fundswereusedmainly tocoverstaffsalaries or incentives and the running costs. There is a financial gap that usually affectsequipment, drugs and consumables for laboratories. That situation resulted in reprioritizing

4 Sudan Health Accounts Report with Specific Diseases Accounts (2015), FMOH, 2017.


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provision of PHC services at the state level. The NHIF’s reimbursement policy is misalignedbecauseitprovidesreimbursementonlyfortheprovisionofcurativePHCservices.

Weakreferralsystemisasharedcommentamongdifferentstates.Thatwasattributedmainlytolackofbasic services at thePHC-levelwhichhas led consequently to amisalignmentbetweenPHC and UHC. Findings show that when PHC facilities lack qualified staff or basic items likelaboratoryservices,patientsoftenbypassPHClevelfacilities.

Inanalyzingtheresultsofthesurvey,theteamfoundthattherearealotofgapsthathinderstheachievementofproperPHCalignmentwithUHCinSudan.Theseincludepolitical,structuralandorganizationaladjustments.

Community Participation in Primary Health Care Delivery: A Mixed Methods Study of the Community-based Health Planning and Services programme in the Builsa North District, Ghana

ShieghardAgalga,FacultyofPlanningandLandManagement,UniversityforDevelopmentStudies,Wa,Co-Authors:ShieghardAgalgaandGilbertAbotisemAbiiro

Background:Communityparticipationisessentialforthesuccessful implementationofPrimaryHealth Care (PHC) programmes. The Community-based Health Planning and Service (CHPS)programme is one of the PHC interventions in Ghana which by design and implementationheavily relies on community participation. However, little is known about the actual levels ofcommunity participation in the various components of the CHPS programme including needsassessment, leadership, organization, resourcemobilization andmanagement, and the factorsinfluencingcommunityparticipationintheprogramme.

Objectives: This study assessed the level of community participation in the planning andimplementation of the Ghana Community-based Health Planning and Services (CHPS)programme and the factors that influence community participation in the programme in theBuilsaNorthDistrict.

Methods:Amixedmethodsapproachwasadoptedinwhichthequantitativedesignwasusedtoassessthelevelofcommunityparticipationwhereasthequalitativedesignwasusedtoexplorethefactorsthatinfluencecommunityparticipationintheprogramme.Asurveywasadministeredto all the 450 CHPS related stakeholders and interviews were administered to a purposivesampleof105ofthesestakeholders.Descriptivestatisticswasusedtoanalyzethequantitativedatawhereasthequalitativedatawasanalyzedusingthematicanalysis.

Key findings: The study revealed a moderate level (56-60%) of community participation invariouscomponentsoftheprogramme.Thecreationofawarenesswithincommunities,abilityofcommunities tocontributematerial resources, strongandeffective local leadershipandahighspirit of voluntarism are the factors promoting community participation, whereas contractingout the construction of CHPS compounds to external contractors, volunteer attrition, lack ofsenseofownershipbydistantbeneficiaries,competingeconomicactivities,dispersedsettlementpatternsandfinancialconstraintsarethemajorfactorsimpedingcommunityparticipationintheprogramme.

Conclusion:VolunteermotivationandtheempowermentofcommunitiestoconstructtheirownCHPScompoundsarekeymeasures thatcanenhanceeffectivecommunityparticipation in theprogramme.


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Operationalization of health districts as a strategy for revitalising primary health care in Ivory Coast

TaniaBISSOUMA-LEDJOU,Dr Yameogo Jean-MarieVianny,Dr LanwisGogouaNahounou,WHOAbidjan,MinistryofHealthandPublicHygieneoftheIvoryCoast

FollowingtheHararedeclaration(1988),IvoryCoastadoptedin1994thedecentralizationofitshealthsystemandthehealthdistrictas itsoperationalunit for the implementationofprimaryhealth care (PHC). Various regulations have been drafted to define the organization andfunctioningofhealthdistricts.

However, after more than a decade of implementation, district performance and healthoutcomesatthenationallevelareunsatisfactory.Maternal,new-bornandinfantmortalityratiosare high, with 614 deaths per 100,000 live births (2012), 33‰ (2016) and 108‰ (2016)respectively, limiting the achievement of the Sustainable Development Goals (SDOs) andUniversalHealthCoverage(UHC).

Indeed,theevaluationofthefunctioningofthehealthdistrictsandotherkeystudiesonPHCandefficiencycarriedoutovertheperiod2016-2017showedthattheseresultswouldbeattributablein part to a policy of strengthening tertiary hospitals rather than PHC. In addition, there areinefficienciesinusingpublicfinancialresources,aninadequatedistributionofhealthpersonnel,insufficient supervisionandmonitoringofproviders, andweakmanagerial capacitiesofhealthdistrictmanagers.

To provide an adequate response, the Ivorian government has committed itself to therevitalization of PHC through the operationalization of health districts considering the above-mentionedparameters.

The methodology of the intervention consisted in strengthening the dialogue between theMinistryofHealthandkeypartners,organizingareflectiononthehealthdistrictsandidentifyingthepriorityareasforaction.

Intermsofresults,aconsultationframeworkbetweentheMinistryofHealthandpartnershasbeen set up with the appointment of a national focal point tomaintain dialogue around thedistrict,asystemforcoordinationandmonthlymonitoringoftheperformanceofhealthdistrictsonthebasisofkeyperformanceindicatorshasbeenestablished,andaframeworkforactionstostrengthenhealthdistrictshasbeendefined.Thisframeworkofactionsaimsatanefficientuseof public funds allocated to health, an equitable distribution of human resources with anemphasis on PHC, an adequate system of supervision, monitoring and evaluation and thestrengtheningofthemanagerialcapacitiesofhealthdistrictmanagers.

Nevertheless,thechallengeremainspoliticalwill,theintegrationofthesecommitmentsintoaninstitutionalframeworkinordertosustainthegainsmade,includingtherealparticipationofthecommunities.


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Parallel Session 4-7 Governance and accountability 1

All hands-on deck: lessons learned from effective multi-stakeholder engagement to strengthen primary health care in Senegal

Dr.KadhySeck,CoordinatoroftheCommunityHealthUnit,MinistryofHealthandSocialAction,SenegalDr.MameCorNdour,ChiefofParty,USAID-fundedHealthSystemStrengtheningProjectimplementedbyaconsortiumledbyAbtAssociates

Background: Many countries are asking how to strengthen primary health care to accelerateprogresstowardsuniversalhealthcoverage.Theinvolvementofallstakeholdersinstrengtheningprimary health care, from the national level to the community level, including the public andprivatesectors,iscrucial.Althoughthisisawell-knownfact,itisrarelyseeninpractice.

Goal:InSenegal,theMinistryofHealthandSocialAction(MSAS)collaborateswithpartnerssuchasHealthSystemsStrengthening(RSS)programandUSAIDto increasecitizens'participation indefining primary health care needs, and in holding their health facilities accountable, and inreducing their financial risks when they need primary care. This presentation will share theexperience, and the positive and negative lessons reached out from the genuine stakeholderengagement,particularlyfromcommunities,toachieveUniversalDiseaseCoverage(UDC).

ResearchObjectives:Theobjectiveofthepresentationistosharetheadvantagesandlimits instrengtheningprimaryhealth care through citizenengagement.Wewill share theoperational,and technical and political recommendations that Senegal must consider in continuing theseuniversalhealthcoverageefforts.ThiswillhelpothercountriesseekingtoacceleratetheireffortsinsupportoftheUDCthroughprimaryhealthcare.

Methodsused:TheauthorsdrawondecadesofcollaborationbetweenMSASandtheUSAID/RSSPlusprograms,theexperienceoftheRSSPlusprojectatthesub-national level insixregionsofSenegal and the lessons reached out from international technical experts to draw in somelessonstolearn.

Mainconclusions:MSASanddevelopmentpartnershaveinvestedinstrengtheningatleastthreecommunityplatformssuchasCommunityRestitutionFrameworks,andMonitoringandAlertingCommittees, and Health Development Committees. These platforms aim to strengthencommunicationbetweenregionalanddistricthealthteams,primaryhealthcarefacilitiesandthecommunity so that (i) community health needs are better defined and addressed by healthfacilities;(ii)thecommunityandtheMinistryofHealthhaveamutuallyaccountablerelationshipand(iii)communitymemberscanengageinepidemiologicalmonitoringandtoimproveSRMNIAandmalaria indicators.Asthiscommunication is two-way,communitymembers, inadditionofgivingtheiropinion,receiveinformationabouttheirhealthsystem,publichealthmessagesandhow to access care without imposing a significant financial load. This knowledge allowedcommunitiestoenrol incommunityhealth insuranceprogram,mutual,sothattheycanaccessprimaryhealthcareservices.

Through these community platforms, local political and religious leaders, communityrepresentatives, public and private health providers, and health workers meet regularly anddiscuss how to improve primary health care services and monitor progress. DHIS2 tools andinformation provided valuable data to enrich these discussions. These efforts have also beensupportedbypartnerssuchasUSAIDbyprovidingdirectfundingtoregionalhealthmanagementteamsinfiveregionstostrengthenprimaryhealthcare.


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Mainconclusion(s):CitizensaretheultimatebeneficiariesoftheUDCandplayanimportantroleinhisachievement.Inadditiontobeingbeneficiaries,theycanalsomakeavaluablecontributiontostrengtheningtheavailabilityandqualityofprimaryhealthcareservices.Theycanensurethattheservicesprovided(i)meettheneedsofthepopulation,(ii)areofahighqualityand(iii)aresustainablethroughnationalfunding.Empoweringcommunitiesabouttheiroptionsforreducingtheirfinancialrisk,forexamplethroughmutual,canalsohelptoensurethatcommunitydemandforprimarycareservicesismetwithoutsumptuaryspending.

Who is More Corrupt: Identifying the perpetrators of absenteeism among health workers in Nigeria.

PamelaAdaobiOgbozor,HealthPolicyResearchGroup,UniversityofNigeriaNsukkaCo-authors:CharlesT.Orjiakor,ObinnaOnwujekwe,PamelaA.Ogbozor,PrinceAgwu,AloysiusOdii,MartinMcKee,EleanorHutchinson,DinaBalabanova Background: Unplanned and voluntary absenteeism is a serious corruption concern amonghealthworkersas itundermineseffectivehealthcaredeliveryandcompromisestrivestowardsUniversalHealthCoverage(UHC).Lowresourcesettingsaremostimpactedbyabsenteeism,yetthenatureofabsenteeism,perpetratorsandmotivatorsarepoorlyresearchedandunderstoodin low resource settings.The rationale of the study is to illuminate absenteeism as a form ofcorruption afflicting the health sector. It is part of a new anti-corruption evidence (ACE)consortium aimed at identifying/providing evidence for types of corruption existing in Low toMiddle Income Countries (LMICs) and subsequently engaging concerned, often grass rootstakeholders,especiallystreetlevelbureaucrats,totacklethecorruption.

Aim: In this studyweaimed to identify: i)whichgroupofhealthworkersaremostlyabsent,ii)factorsthatcontributetoabsenteeismamongeachgroupandiii)effectivestrategiesandpoliciesthatmaybevaluableincheckingabsenteeismamonghealthworkersinNigeria.

Method: A qualitative design and approach to investigating corruption was adopted. Healthworkers (N = 18: 6 physicians, 6 nurses, 6 health administrators) and 6 service users wereinterviewedusing in-depth interview topic guides. Thematicdataanalysiswasused toexplorethedata.

Keyfindings:Healthworkersinruralareaswerereportedtobemoreabsentfromwork.Driversofabsenteeismwerelowpatientload,poormonitoring/supervisionandpoorsocialamenitiestosupportlivingandworkingconditions.Primaryhealthcentresreportedlyhadhigherabsenteeismthanotherlevelsofformalhealthcare,astheywereoftenlocatedinruralregions.Itwaswidelyreportedthatabsenteeismwasoftennoticedamonghigherrankingstaff,albeitseniordoctorswereobserved tobe themostabsent spurredbydualpractice.The results showed that therewere cover-up processes for absent staff. No disparity was observed in the frequency ofabsenteeismbetweenmalesandfemales.However,familyroleswerereportedtobeimplicatedinfemaleabsenteeism,whereas,dualpracticeandacallouspersonalitywereblamedformaleswho were absent. The use of biometrics to monitor absenteeism has not been effective forhealthworkersespeciallyinruralareas.

Main Conclusion: The findings are helpful to health policy researchers and policy makerstargetinggroupsthataremorelikelytoabsentfromworkinspecifichealthsettings.Motivatorsfor absenteeism for the different groups could be targeted in interventions aiming to reduceabsenteeisminthehealthsector.


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Identifying and prioritising health sector corruption in Nigeria.

CharlesTochukwuOrjiakor,HealthPolicyResearchGroup,UniversityofNigeria,Nsukka

DepartmentofPsychology,UniversityofNigeriaNsukkaCo-authors: Obinna Onwujekwe, Charles T. Orjiakor, Eleanor Hutchinson, Martin Mckee, Prince Agwu,ChinyereMbachu,AdaobiOgbozor,UcheObi,AloysiusOdii,HyacinthIchokuandDinaBalabanova Background:Corruptioniswide-spreadinthehealthsector,withnegativeeffectsonhealthandaccesstocare.However,thereispaucityofknowledgeonthesubjectofcorruptioninNigeria’shealth sector: its systemic nature, and ways institutions and social systems drive corruptpractices.UnderstandingcorruptpracticesthrivinginhealthsystemsisimportantinpositioninghealthsystemsforUniversalHealthCoverage.

Aim: Toexamineexistingtypesofcorruption,the incentivesthatenablecorruptpracticesandthewaysandmeansofreducingsuchcorruptpractices intheNigerianhealthsystem.Thiswilltheninformtheplanning,designingandimplementationoffeasiblehigh-impactanti-corruptionstrategiesinNigeria. Methods: A systematic review of literature identifying corrupt practices reported in studiesfocusingonNigeriawasconducted.Tofurtheridentifyandprioritisemaintypesofhealthsectorcorruptpracticesandtheirpossiblesolutions,aprioritysettingworkshopusingNominalGroupTechnique (NGT) with 30 frontline health workers was held. The NGT was used to prioritizedifferent types of corrupt practices according to their significance inNigeria and how feasibletheycouldbeaddressed.MicrosoftExcelwasusedtoassignnumericalweightstotherankingsmade by participantswith themost disturbing and addressable corruption emergingwith thegreatestvalueandtheleastcorruption,theleastvalue.

KeyFindings:Intheliteraturereview,50publicationswerereviewedidentifyingawiderangeofcorrupt practices in Nigeria’s health sector. In the NGT, frontline health workers originallyidentified 49 types of corruption which was later aggregated to 19 distinct corruption types.Rankingandre-rankingsessionsrevealedthetopfivecorruptpracticesthatemerged(withtheirweightedscores)tobe:absenteeism(53),procurement-relatedcorruption(34),under-the-counterpayments(33), health financing-related corruption(28), and employment-related corruption(26).ParticipantsintheNGTagreedthatsomeofthecorruptpracticescouldbemeaningfullytackledusinghorizontalapproachesthatexclusivelyinvolvehealthworkers,streetlevelbureaucratsandcommunity groups. Findings from the systematic review corroborated with corruption typesidentifiedandratedbyfrontlinehealthworkersandpolicymakers.

MainConclusion:CorruptionispervasiveintheNigerianhealthsector,butthereare‘horizontal’solutions that can be implemented at the health facility and community levels to reduce thescourgeand improvehealth systemperformance.Further studieswillbeundertaken to revealthepreferencesofhealthworkersofthewaysandmeansthatcouldbeusedtotacklethemostcommoncorruptpractise,whichisabsenteeism.

Use of health facility committees to improve health system governance and accountability: Institutionalization and Sustainability issues in Enugu State Nigeria

UzochukwuBSC,OkekeCC,OnwujekweOE,EtiabaEHealthPolicyResearchGroup,CollegeofMedicine,UniversityofNigeria,Enugu-campusIntroduction/background:FacilityHealthCommitteesorHealthFacilityCommitteeshavebeenaround for some years in Nigeria in various guises. It was originally designed for the BamakoInitiative’s promotion of Drug Revolving Funds but has expanded to improve health system


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governance. However, there are sustainability issues with the establishment of thesecommitteesespeciallyinareaswheretheyaresupportedbyadonorprogramme

Objective(s):Toexplore the institutionalisationand sustainabilityof thesecommitteesbeyondthelifeofadonoragencythathadsupportedtheinitiativeinEnuguStateNigeria.

Materials and methods: Desk review of documents and Key stakeholders’ interviews (IDIs &FGDs).Thebasicassumptionwasthatcommitteeswouldbe institutionalisedandsustainable iftheyhave strong internal relevance, viability and functionality;are well integrated into theirrelevantcommunityandinstitutionalenvironment;andarecapableofrenewalandreproductionwithoutdonorsupportedassistance.

Results:Committees’ internalviabilitykeyfactors includedPayments;Composition;Mentoring;LGA Role; Membership renewal; Threat of Ward Development Committees; Training andavailability of Printed Reference Materials. The key factors that enhanced integration andreplicationincludedintegrationintotheState,LGAandcommunityHealthSystemandScalingupmechanism.

Conclusionand recommendations: InstitutionalisationofFHC isessential forsustainabilityandmaintaining the positive impact of FHCs especially with their proposed role in theimplementation of BHCPF and other health financing reforms inNigeria. It should be pursuedwithinstitutionsinthecommunity,LGAandtheStatehealthsystem.AFormalagreementwiththeStatehealthsystemisdesirable

Governance challenges and solutions within a free Maternal and Child Health (FMCH) services programme: Re-visiting the SURE-P MCH programme in Nigeria

BenjaminUzochukwu,EnuguUNN

Introduction/background:Healthgovernanceisthetotalityofwaysinwhichasocietyorganizesand collectively manages its health affairs. The Subsidy Reinvestment and EmpowermentProgramme (SURE-P) included MCH related interventions referred to as SURE-P/MCH. It waslaunched on January 2012, but was shut down in April 2015 following emergence of a newNational government. The programme was aimed at improving access to quality free MCHservices.Thereisneedtolookatthelessonslearntaroundgovernanceofsuchprogrammes.ThiswillinformtheplanningandimplementationoffreeMCHservicesaswillbeprovidedbyrecenthealthfinancingprogrammereformsinNigerialiketheBasicHealthcareProvisionFund(BHCPF)

Objective(s):ToexplorethegovernancechallengesandsolutionswithinthefreeMCHservicesintheSURE-PMCHprogramme.

Materials and methods: Document Reviews, IDIs and FGD as part of an ongoing RealistEvaluation of the SURE-P/MCH programme. The Siddiqia et al. 2009 framework for assessingHealthSystemsGovernancewasusedforanalysis

Results:Thekeychallengesincludedissuesaroundstrategicvision;participationandconsensusorientation; ruleof law; transparency; responsivenessof institutions; equity; effectivenessandefficiency;accountability;informationandethics

Conclusionandrecommendations:TheFMCHwithintheSURE-P/MCHprogrammewasfraughtwith lots of challenges.Access to information, social accountability efforts, increasedeffectivehealthreporting,financialaudits,equity,inclusivenessandothersareassociatedwithimprovedgovernance of the FMCH. The information provided here will assist development andimplementationofsimilarFMCHprogrammesinNigeriatoensuregoodgovernance


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OS 12 – Teaching Health Economics – a LMIC focus

AfHEAOrganizedSession:TeachingHealthEconomics

Concept:Healtheconomicsresearchandanalysishassubstantialpotential toprovidesolutionsto some of themost critical challenges in health policy, resource allocation, and financing incountries around theworld, andparticularly in resource-constrained environments in low andmiddle-incomecountries(LMICs).

However, the capacity to provide and utilize this research and analysis is contingent on asustainablepipelineofindividualswiththeskills,knowledgeandattitudesinhealtheconomics,which in turn is relianton local universities andeducational facilities offeringhighquality andcomprehensivecoursesandresearchopportunities.

In high income country settings, there has been a proliferation of training and educationalopportunities in health economics in the past 30 years commensurate with the growth andimportanceofhealtheconomics research insupporthealthpolicy.Growth in targeted trainingandeducationalopportunitiesinLMICsettingshasalsoincreasedinrecentyears,inadditiontohigh-incomecountry institutionsoffering teachingspecifically targeted toLMICsettingsand/orofferingteachingtoindividualsfromLMICsettings.

This90-minute sessionwill explore the current statusof teachinghealtheconomics inand forLMICsettings,withspecificfocusonsub-SaharanAfrica.Thesessionwillpresentexamplesfromexistinginstitutionsandwillopendiscussiononchallengesandopportunitiesforteachinghealtheconomics in LMICs. The discussant, representing theWHO,will reflect on the range of shortcourses in health systems and financing currently offered by theWHO and the potential forsynergiesbetweenshortcoursesandformaldegreeprogramstomeettheneedanddemandforhealtheconomicsintheregion.

Speakers/institutions:• Dr Justice Nonvignon, Department of Health Policy Planning and Management,

UniversityofGhana• ProfVincentOkungu,SchoolofPublicHealth,UniversityofNairobi• ProfMoustapha Thiam, Institute for Public Health and Reproduction Research, Cheikh

AntaDiopUniversity,Dakar,Senegal(InstiutdeFormationetdeRechercheenPopulaitondevelopmentetsantédelaReproductiondel’UniversiteCheikhAntaDiopedDakar)

• MrTommyWilkinson,HealthEconomicsUnit,UniversityofCapeTown,SouthAfrica• DrJoleneSkordis,CentreforGlobalHealthEconomics,UniversityCollegeLondon

Discussant:MatthewJowettt,WorldHealthOrganizationChair:DiMcIntyre,EmeritusProfessor,HealthEconomicsUnit,UniversityofCapeTown


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JoleneSkordis,UniversityCollegeLondon,InstituteforGlobalHealthEconomics

Foundedin1826,UCLhasalonghistoryofEconomicsteachinginLondon.However,onlyinthelast two decades has Health Economics emerged as a separate taught discipline. UCL’sDepartment of Economics offers a technical module on the Economics of Health aimed atadvanced Economists, while UCL’s Institute for Global Health offers modules on the ‘KeyPrinciplesofHealthEconomics’ and ‘EconomicEvaluation,’whichareopen to students fromawiderrangeofdisciplines.

More recently,UCL identified theneed tobetterdevelop capacity inHealthEconomics and in2017launchedanewMScinHealthEconomicsandDecisionScience.Thepractiseandteachingof Health Economics is commonly characterised by the integration of different expertise andperspectives including micro-economics, medical statistics, epidemiology, philosophy andmanagement. UCL’s MSc in Health Econonmics and Decision Science aims to embrace thisdiversityandpreparestudentswithsolidtheoreticalfoundations,whileallowingthemtochooseappliedpathwaysthatfocusoneitheradvanceddecisionsciencemodellingoradvancedappliedeconomic theory. In doing so,we cater for able students from awider range of backgroundsincluding Economics,Medical Statistics, Epidemiology, AppliedMathematics andDemography.Uniquely, students on this programme are able to select a dominant ‘context of interest’,focussingeitheronthehealthsystemsandpoliciesofhighincomecountries,ortakingaglobalviewofhealth systemsandpolicy thatplacesequalweighton low incomecontexts. Studentsarerequiredtotake8modulesandcompleteasubstantivepieceofresearchasadissertationorproject. Very able studentsmay go on to study for doctoral degrees, usually within the UCLInstituteforGlobalHealthEconomics,wheretheycantakeadvantageofthesubstantivebodyofworld-leadingresearchalreadyunderway.Thatresearchspanseverycontinentontheglobeandstudents are usually able to work on questions relevant to their own home context. Whilescholarships for masters level study are available from the Commonwealth Trust, fewapplications are received from African Scholars each year. This under-representation is thenmagnified at the doctoral level, where full funding is more scarce. Our program faces a keychallengeinattractingexcellentAfricanScholarstothestudyofHealthEconomics.

MrTommyWilkinson,HealthEconomicsUnit,UniversityofCapeTown,SouthAfrica

The sessionwill present the approach to teaching health economics at the Health EconomicsDivision(HED)intheSchoolofPublicHealthandFamilyMedicine,UniversityofCapeTown,anddescribe how this contributes to strengthening capacity in skills, knowledge and attitudes inhealtheconomicsinsupportofUniversalHealthCoverage(UHC)intheregion.

The HED is integrated with the research outputs of the Health Economics Unit (HEU) at theUniversityofCapeTownandoffersthreemainteachingstreams:thespecialisthealtheconomicsprogramme within the Master’s in Public Health, the post-graduate diploma on healtheconomicsandadoctoralhealtheconomicsprogramme. Inaddition,HEDstaffcontribute toarange of courses at post and undergraduate level across the University’s school of healthsciencesandbusiness.

TheHEDteachingcoverscentralconceptsinhealtheconomics,includinghealtheconomictheoryandmicroeconomics, economic evaluation and decagonsmaking, population health, strategicpurchasingandhealthfinancingandorganization.TheHEDconsistsofeightstaff,withnumerousguestlecturesonspecialisttopics.

The post-graduate diploma in health economics can be completed remotely with dedicatedonsiteblock teaching.Due to its formatanduseofonline resources, it contributes tobuilding


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basic health economics skills and knowledge amongst those that may not have capacity toundertake formalMaster’s level instruction and research, such as healthmanagers and policymakers.Assuch,itisahighlypopularprogramandlimitedbyavailablefaculty.

Key challenges associated with teaching health economics at HED include ensuring dedicatedtime to dedicate to student teaching and supervision and ensuring appropriate support forstudents’post-graduation,particularlyforindividualsmovingintopolicyorhealthmanagement.Continuing to strengthen national, regional, and global networks for programme qualityimprovement and external supervision will contribute to the division’s capacity strengtheningactivities.Dedicatedfundingtoexpandteachingoutputswouldassistincoursedevelopmenttomatchthedemandforhealtheconomicsteachingtoavailablesupplyinasustainablemanner.

JusticeNonvignonUniversityofGhana

Theobjectiveofthispresentationistodescribethecurrentstatusofteachinghealtheconomicsand related courses at the University of Ghana and contribute to discussion on the futuredirection of teaching health economics in Africa through sharing current challenges andopportunitiesinthearea.ThepresentationwillalsohighlighttheneedforacollaborativeeffortacrossinstitutionsinAfricawhichhaveastrongcapacityinteachinghealtheconomics,inordertoshareinnovationintechniques.

TheUniversityofGhanaSchoolofPublichealthwasestablishedin1994throughacollaborationwiththeMinistryofHealthandtheUniversityofGhana,totrainmid-levelmanpowerrequiredtochampionhealth sector reforms inGhanaand in thesub-region.Oneof sevendepartments intheSchoolofPublicHealth, theDepartmentofHealthPolicy,PlanningandManagementhostsandteachesgraduatelevelcoursesinhealtheconomicsandrelatedareas,includingtoMasterofPublic Health, MSc Monitoring and Evaluation and doctoral students. The full-time facultystrength of eight – four of whom are trained health economists – and affiliate faculty fromcognateinstitutesacrosstheUniversity–sixofwhomhavetraininginorexperienceinteachinghealth economists. The department also hosts the Health Economics, Systems and PolicyResearch Group of the University of Ghana, which comprises nine faculty across universitydepartmentswithexpertiseinhealtheconomics,systemsandpolicy.Inadditiontothecoursesabove, thedepartment isalsopreparing torolloutaMasterofHealthEconomicsProgramme,whichisatfinalstagesofaccreditationbyrelevantnationalbodies.

The department, through its faculty, maintains collaborations with leading health economicstraining institutions inAfrica, Europe andNorthAmerica,with awide network of peoplewhocontribute to teaching throughguest lectures,andtosupervisionofdoctoral students throughserving on advisory committees of students. Key challenges include high demand fromprospective students with limited space and faculty to teach and supervise them in healtheconomics. An innovative solution to the above could be reassessing and institutionalizingteaching collaboration across African institutes expand health economics capacity on thecontinent


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ParallelSession5-Oralpresentations

Parallel session 5-1 – Health Financing and policy

Evaluation of Public Policy for Population Wide Health Reforms in Sub-Saharan Africa; A Critical Review of Salt Reduction Policies in South Africa & Nigeria

Amable Ayebare, LiverpoolSchoolofTropicalMedicine

Background:Amaximumdietarysalt intakeof less than6gperday is therecommendedadultguidelines fromtheWorldHealthOrganisation. Increasedsalt intake isaknownrisk factor forraised blood pressure (hypertension) which in turn increases the chances of developingcardiovasculardiseasesamongmanyothernon-communicablediseases(NCD's)

Rationale:NCD’saretheleadingcauseofmorbidityandprematuremortalityintheregion.Withtheexistinghealthsystemsalreadygrapplingwiththeburdenofcommunicablediseases;limitedresourcesandincreasingeffectsofurbanization;thereisneedtofacilitatetheuseofpopulationwidehealth interventionstoreducetherising incidenceofNCD’s.This is in linewithachievingtarget3.4oftheSDGagenda:reducebyonethirdprematuremortalityfromnon-communicablediseasesthroughpreventionandtreatmentandpromotementalhealthandwell-beingby2030.

Aim:Toevaluatetheexistingpoliciessupportingpolicyenvironmentonsaltreductioninthesub-Saharan Africa with particulate goal of gaining insight on policy development processes andimplementationstrategiesand theireventual impactonpopulation-widehealthoutcomesandreforms

Methods:Usingdocumentanalysis; theexistingpublicpoliciesonsaltreduction inNigeriaandSouth Africa were reviewed against pre-set criteria from global recommended guidelines.Policies were also examined using checklists developed from known policy evaluationframeworkstoassessrelevancetocauseandutilitytocontext

Findings: Most countries in SSA do not have national gazetted salt policies. The few existingpolicies are backed by context specific needs assessment. There is limited stakeholderengagement in policy processes and discussions and approaches to implementing the publicpolicies isn’t based onwhatworks. Both countries showcased limited evidence onmonitoringandevaluationstructuresofexistingpolicies.

Conclusion: There isneed to invest in context-drivenempirical researchcoupledwith relevantmulti-stakeholder partnerships during the process of policy formulation. Both approaches toimplementing public policywhen cohesively planned out present viable pathways to not onlyreducingtheincidenceofNCD'sbutinthelongrunachievethehealthrelatedSDG's


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Macro-economic determinants of public expenditure for health in sub-saharian african countries

GnandeRomeoBoye,CIRES

TheWorldHealthOrganizationispromotinguniversalhealthcoveragetoreachthethirdpointoftheSustainableDevelopmentGoals.Fundingfromthepublicsectorisessentialtomovetowardsthisgoal.Buthowcanthisfundingbefurtherincreasedinsub-SaharanAfricancountrieswhereincomelevelsarealreadylow?Andwherethepovertyrateforhimwasaround41.1%in2015.

A UN study in 2015 suggests increasing public health spending as a function of GDP growth.Indeed,anincreaseinGDPleadstoanincreaseinpublichealthexpenditure.Butotherauthorsfindthathealthspendingingeneral,respondveryweaklytothechangeinincome.Thissituationisexplainedbythefactthatincomeisnottheonlyfactorexplainingtheincreaseinpublichealthexpenditure. Indeed, some authors refer to political and institutional factors as the mainexplanatory factors for the increase in public health expenditure. In the case of Sub-SaharanAfricancountries,whatarethefactorsthatinfluencetheevolutionofpublichealthspending?

Theobjectiveofthisarticleistodeterminetheexplanatoryfactorsofpublichealthexpenditureinsub-SaharanAfrica.

The analysis in this study is conducted using a nonlinear model on which the generalizedmoments method was applied based on a sample of 30 countries in sub-Saharan Africa andobservedfrom2000to2015.

Themainfindingsofthisstudyindicatethatforthemajorityofcountriesinsub-SaharanAfrica,thevariablesthathaveapositiveeffectontherelativeshareofpublichealthexpenditureinGDPare: the growth rate of GDP, democracy, the ability to collect taxes and the fair allocation ofpublic resources. In addition, the results of the estimates show that social unrest leads to adeclineintherelativeshareofpublichealthexpenditureinGDP.

Theresultsofthestudyimplythatthemainexplanatoryfactorsofpublichealthexpenditurearethecurrentfiscalcapacityofcountries,theprioritygiventohealthandthesoundmanagementofpublicresources.Inthisperspective,broadeningthetaxbaseandimprovinggovernancecouldincreasepublichealthspendinginsub-SaharanAfricancountries.

Fiscal Space for Health at Decentralized Level: The Potential Impact of Fiscal Arrangements in Kenya

Kenneth Mungej, PhD Fellow, Initiative to Develop African Research Leaders, KEMRI Wellcome TrustResearchProgrammeEdwineWBarasa,HealthEconomicsResearchUnit,KEMRIWellcomeTrustResearchProgrammeKaraHanson,FacultyofPublicHealthandPolicy,LondonSchoolofHygieneandTropicalMedicineJaneChuma,SeniorHealthEconomist,WorldBankKenyaCountryOffice

Background Universal health coverage (UHC) arrangements anticipate a significant role forpublic expenditure. Fiscal space for health is the capability of a government to assign moreresourcestohealthwithoutaffecting its financialandeconomicposition.Whilefiscalspaceforhealthisusuallyassessedatnationallevel,decentralizationisafeatureofmanyhealthsystems.Theobjectiveofthestudywastoperformacriticalassessmentofthefiscalspaceforhealthatdecentralized(county)levelinKenyaanditsimplicationsontheattainmentofUHC.

MethodsWeusedaqualitativemultiplecasestudyapproachwiththeunitofanalysisbeingthecounty.Wedevelopedandappliedaconceptual framework thataccounted for changes in thegovernment-citizen relationship and the four pillars of fiscal decentralization: revenue and


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expenditure assignments, intergovernmental transfers and subnational borrowing. Three casestudy countieswerepurposively selectedbasedon their level ofown revenuegenerationandpublic health expenditure (PHE), and sophistication of health systems. Data were collectedthroughdocumentreviews(statutes,policies,andreports),in-depthinterviews(n=25)andfocusgroupdiscussion(n=17)withcitizenswhoweremembersoforganisedgroups(e.g.community-basedorganisations).

Results Expenditure and revenue assignments were described in policy and supported byinstitutional arrangements. There was overlap in performance of functions, others wereneglected, and institutional arrangements to address conflicts did not function as required,thoughthe impactonPHEwasunclear.Fiscaldecentralizationresulted inhigh levelsofcountyPHE. Conditional grants that were earmarked and supported by contracts and organizationalcapacitytomonitorperformanceincreasedPHE.PHEwasnegativelyimpactedbyinappropriatebudget constraints e.g. fixed ratios on development and recurrent spending. PHE was alsonegatively influenced by poor vertical transfer and conditional grant design, irregularity offinancial flows, planning capacity gaps, and favouring of capital expenditure. Service mixremained unchanged even though the design and implementation of conditional grantsdisruptedcountyplanningactivities,encouragedhospital-centricexpenditure.andunderminedaccountabilitybetweennationalandcountylevels.

Discussion/Conclusions Well-functioning institutional arrangements will address conflicts inexpenditureassignmentsandotherimplementationchallenges.Dependencyontransfersfromcentral level is likely to continue in thenear term. Thedesign andoperationalizationof thesetransfers, and of conditional grants in particular, is critical to ensuring county-level PHE helpsmeetequity,efficiencyandqualityofcaregoalsofUHC.

Demonstrating the benefits of investing in rehabilitation: evidences from 3 Sub-Saharan African countries studies AnnaBoisgillot,LyonCERDI,Humanity&Inclusion

Background Integratedrehabilitationservicesinthehealthsystemareoneofthechallengesofthe universal health coverage and the WHO dynamic “Rehabilitation 2030”. Persons withdisabilities are the most expose to catastrophic financial risk, and it is particularly due toadditionalspecificcareneededandahighunemploymentrate.

Aims and objectives of the research This study aims to assist rehabilitation stakeholders tostrengthenthehealthsystemtoproviderehabilitationservices throughasituationassessmentof the financial access to rehabilitation services in low-income Sub-Saharan African countries.This study seeks to describe and analyze the rehabilitation sector in financial and economicterms,andidentifiesitsstrength,weaknessandpriorities.

Methods The analysis focused on three low-income economies, Burkina Faso, Rwanda, andMadagascar where economic studies were conducted respectively in 2015, 2017 and 2018.Policydocuments,past researchand studieson financial access to rehabilitation serviceshavebeenstudied. Interviews,with semi-structuredquestionnaires,havebeenorganizedwith stateand non-state actors involved within the rehabilitation sector. This evaluation analyzed thefinancing of this sector for all its components from human resources to social protectionprogramsinaimtohighlighttheestimatedgapofinvestmentforthissector.

Results This study highlighted some convergences in the rehabilitation sector between thesethree countries. We observed a lack of protection mechanisms for persons who needrehabilitationcare,inparticularforprostheticsandorthotics,inadditiontogeographicalbarrier


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thatreduceaccesstothesehealthcareservices.Anotherstrongpointofconvergenceisrelatedto a shortage of human resources for rehabilitation care that need to be financed. InMadagascar, more than 24 000 physiotherapists are missing to satisfy the demand forrehabilitationcareinthecountry.Alargeinvestmentfromthegovernmentisrequiredtocoverthevariousneedsofthissector. InRwanda,there isaneeded investmentfrom20%to36%oftheMinistryofHealthbudget.

ConclusionDespitesignificanteffortsfromgovernmentstolegallyformalizeandimproverightsof personswithdisabilities, applicationsof laws, and taking careof this issue remains limited.Many opportunities exist to improve accessibility to quantitative and qualitative rehabilitationservices in these countries, national efforts must strengthen the health system in order toprovide available rehabilitation services at all levels of healthcare. Analyses of financing ofrehabilitationservices inthehealthsystemprovideguidancefor thegovernmenttodetermineappropriate financing volume and mechanisms, especially for informal sector persons. Theobjectiveofuniversalhealthcoveragewillnotbereachedifrehabilitationisnotapriorityofthegovernment.

Key words: Rehabilitation, equity, UHC, health financing, social protections, sustainablefinancing,personswithdisabilities,Africa

Fiscal Policies for Health 1GavinSurgey,2PeterHangoma,2MaioBulawayo,2MwimbaChewe,1NickStacey,1KarenHofman1PRICELESSSA(PriorityCostEffectiveLessonsinSystemStrengtheningSouthAfrica)SchoolofPublicHealth,FacultyofHealthSciences,UniversityofWitwatersrand2SchoolofEconomics,UniversityofZambia

OBJECTIVE Zambiaisexperiencingariseinthemortalityandmorbidityassociatedwithobesityrelatednon-communicablediseases (NCDs); including cardiovascular disease, diabetesmellitus(Type II), and cancers. This will all have an associated cost of treatment, specifically with theintroductionofthenewlyintroducedNHIFbill.

The excessive consumption of sugar from non-alcoholic caloric beverages such as sugar-sweetenedbeverages(SSB),hasbeenassociatedwithobesityandrelateddiseasessuchasCVDsanddiabetes.The introductionofa sugar taxhaspotential to reduce theburdenofNCDsandraiserevenuewhichwilladdtotheZambianBudget

METHODS Amathematicalmodelwasdeveloped inMicrosoft Excel to simulate theeffectsofintroducingaSSBtaxinZambia.BaselineconsumptionvaluesforSSBsandtheirsubstituteswerederived from the 2015 Zambia Living ConditionsMonitoring Survey (LCMS) data. Age and sexspecificBodyMassIndex(BMI)werecomputedfromthe2017ZambiaNCDSTEPSSurvey.Own-price and cross price elasticities from the literature were applied to find the effect of a 25%excise tax on SSB consumption, energy intake and the corresponding change in BMI, obesityprevalence, deaths averted, and life years gained.We conductedMonte Carlo simulations toconstruct 95% confidence bands and sensitivity analyses to account for uncertainties in keyparameters. RESULTSOvera40-yeartimehorizon,a25%SSBtaxwasfoundtoavert2,526deaths.ThetaxwasfoundtopotentiallygenerateanadditionalUS$5.46million(95%CI:US$4.66million–US$6.14million)inrevenueannually.

DISCUSSIONANDCONCLUSIONS TheintroductionofanSSBtaxinZambiahasthepotentialtosignificantlydecreasetheamountofdisability-adjustedlifeyearslosttolifestyle-relateddiseaseinwomen,highlightingimportanthealthequityoutcomes.WomenhavehigherbaselineBMIand


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thereforeareathigherriskforNCDs.Inaddition,thesignificantrevenuegeneratedthroughtheintroductionofanSSBtaxmaymakeanimportantcontributioninfinancingtheZambianhealthsystem,giventhelimitedfinancingoptionspresentlyavailable.

Utilization of free maternal healthcare services under the National Health Insurance Scheme in rural Ghana: Results from the Kintampo Health and Demographic Surveillance System (2005 – 2015)

RebeccaKyerewaaDwommohPrah.KintampoHealthResearchCentre.StephaneyGyaase,TheresaTawiah,MahamaAbukari,KwakuPokuAsanteBackground: Thousands of women die yearly through pregnancy and childbirth and this ishighest in Sub-Saharan Africa. This can be reduced through improved access to skilled andemergencycareservicesinthesecountries.Howeverformostpoorhouseholds,lackoffinancialresources hinder the ability to access skilled delivery. In 2008, the Government of Ghanaintroduced a policy on freematernal healthcare under theNational Health Insurance Scheme(NHIS) to provide access to free maternal healthcare services for all pregnant women andnursingmothersresidentinGhanaandreducematernalmortality.

Aim: To assess the trends in the utilization of maternal healthcare services and maternalmortality in rural settings in Ghana, following the introduction of the policy on freematernalhealthcareundertheNHIS.

Methods: Secondary data from longitudinal household surveys on pregnancies and deliveriesconductedintheKintampoNorthMunicipalityandKintampoSouthDistrictinGhanafrom2005to2015wasusedforthisanalysis.ThesesurveyswereconductedbytheKintampoHealthandDemographic Surveillance System (KHDSS) and it involved all pregnant women and nursingmotherswithin theKHDSSstudyareas.Theanalysis comparedstatistics frombeforeandafterthe implementation of the policy to determine trends in utilization of maternal healthcareservicesandmaternalmortality.Stataversion13.1wasusedfortheanalysis.

Thekeyfindings:Utilizationofmaternalhealthcareservicesincreasedaftertheintroductionofthepolicyin2008.Facilitydeliveryincreasedfromlessthan30%priorto2008toabout55%in2015,(eightyearsaftertheintroductionofthepolicy).Thiswasmatchedbyadeclineinhomedeliveries from above 50% prior to 2008 to about 34% in 2015. The percentage of womenattendingfourormoreAnte-natalcarevisitsincreasedfromlessthan1%priorto2008toabout68%in2015.Maternalmortalityalsodecreasedovertimeafter2008.Asat2015about76%ofthestudypopulationwerecoveredbythepolicy.

The main conclusion: Utilization of maternal healthcare services increased after theimplementationofthepolicyonfreematernalhealthcareundertheNHISin2008.Increasingthecoverage of the policy could further improve access to maternal care services, especially forwomenfrompoorerhouseholds.

Financing Universal Health Cover (CMU): a single agency funded by a tax on products

*MansoumNDIAYE,**HervéLAFARGE*CESAG,**ParisDauphineUniversity

Context.Financial riskprotection isacomponentofUniversalHealthCoverage(UHC),which isdevelopingwithdifficultyinWestAfricancountries.Itfacesthecharacteristicsofthecontextofpoverty: a largely informal economic activity, the omnipresence of the behavior of financialresourcesandtheweaklegitimacyofthepost-colonialstates.Povertyhaseverywhereimposed


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compulsory social protection, the informal imposes voluntary contributions, the capture ofmoneyunderminesmicroinsurance,thelowlegitimacyofthestatecreatesmistrust.

Goal.Demonstrate the feasibility andpotential of aCMUdevice consistingof a singleagency,fundedmainlybyataxonproducts.

Objectives:

1) AnalyzethestrengthsandweaknessesofCMUdevicesdevelopedinFrancophoneWestAfrica.

2) Evaluatethefinancingneedsofasingleagencyactingasapayingagent3) Evaluatethefinancingpotentialofataxonproducts4) Showtheregulatorypotentialofthisdevice.

Methods:Makeadocumentaryanalysisoflaws,decrees,draftlawsanddecrees,nationalhealthaccounts,statebudgets.

Results All states aredeveloping anddevelopingCMU schemesbasedon the strengtheningofexistingmechanisms(AMO,free)andthedevelopmentofvoluntaryandsubsidizedmembershipmutuals.Thislastpartisalsothemostproblematic.

Universal and sustainable coverage requires the establishment of a unified, non-contributoryfacilityfinancedfromdomesticresources.

Asystemconsistingofasingleagencythattakescareoftheinvoicesofallcitizens,financedbyataxonproducts(VATtypeandcustomsduties),seemseconomicallysustainable.

Thisarrangementhasastrongpotentialtostrengthentheinformationsystemandregulationofthesupplyofcare.

Conclusion:Sucharrangementshouldbeexperimented.

PHC and Healthcare financing by income tax revenues, and inequalities reduction in Côte d'Ivoire

OlivierZohoréKOUDOU,Ph.DCandidateinEconomics,UniversityFélixHouphouëtBoignyofAbidjan-Côted'Ivoire

Background: Inmost developing countries, the goal of universal health coverage (UHC) is noteasytoreachduetothefactthatlarge,resource-poorpopulationshavelimitedaccesstohealthservices.Given that resource-poor people cannot affordout-of-pocket health expenditures, orcan pay for them only by sacrificing other priorities, a health financing system under whichpeoplearerequiredtopayforusedirectlyisoneofthemajorbarrierstoreachingUHC.Althoughcost sharing is necessary to prevent the overutilization of health services arising from thepotentialproblemofmoralhazard,universalcoverageismorelikelytobereachedwhentheout-of-pocketratiofordirectpaymentissufficientlylow.

Objective:Ourpaper studies the impactof tax-financeduniversalhealth coverage schemesonmacroeconomicaspectsoflaborsupply,assetholding,inequality,andwelfare,whiletakingintoaccount features common to developing economies, such as informal employment and taxavoidance,byconstructingadynamicstochasticgeneralequilibriummodelwithheterogeneousagents.Agentshavedifferenteducation levels,employmentstatuses,and idiosyncraticshocks.Thispaper tries to fill the researchgapbyexploring the followingquestions. First,what is theimpact on individuals in terms of their optimal decisions for labor supply and asset holdings?


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Second, what are the impacts on inequality and social welfare? Third, what are the differentimpactsatboththeaggregateanddisaggregatelevels?

Methods: To quantitatively answer these questions, the paper adopts a modern dynamicstochasticgeneralequilibriumframework,whichisbeingincreasinglyusedforthestudyofsocialsecurityandpublicfinance.Broadly,thepaperaimstoprovidearigidframeworkforevaluatingsuch socioeconomic policies that can help policy makers to understand the impacts acrossdifferentsocialgroups,aswellastheaggregatedoutcomes.

Result/conclusion: Given three tax financing options, calibration results based on the Ivorianeconomy suggest that the financing options matter for outcomes both at the aggregate anddisaggregate levels. Universal health coverage, financed by labor income tax revenue, couldreduce inequality due to its large redistributive role. Socialwelfare cannot be improvedwhenlabordecisionsareendogenousanddistortionsarehigherthantheredistributivegainsforalltaxfinancing options. In the absence of labor supply choice, mild welfare gains are found. In abroadersense,thepaperaimstoprovideaframeforpolicyevaluationofsocioeconomicpoliciesfrombothmacroandmicroperspectives,takingdifferentsocialgroupsintoconsideration.

A review of the incidence and determinants of catastrophic health expenditure in Nigeria: implications for universal health coverage

Background:. Health expenditures that result in financial hardship or impoverishment arecatastrophicandimpedeUniversalHealthCoverage(UHC).Everyyear,some100millionpeoplefallbelowthepovertylineasaresultofout-of-pocketexpendituresonhealth,andafurther1.2billion,alreadylivinginpoverty,arepushedfurtherintopenuryforthesamereason.Threekeypreconditions for Catastrophic Health Expenditure (CHE) identified as availability of healthservicesrequiringpayment,lowcapacitytopay,andthelackofprepaymentorhealthinsurancearepresentinNigeria.ThemostwidelyusedthresholdsforCHEare10%ofthehousehold’stotalconsumptionand40%ofthehousehold’sconsumptionnetofexpendituresonbasicnecessities(capacity to pay). The aim of this review was to review studies conducted on incidence anddeterminantsofCatastrophicHealthExpenditure(CHE)inNigeria.

Methods:Thisstudywasasystematicreview.AMEDLINEEntrezPubMedsearchwasperformedin August 2017 and studies on household (HH) incidence and determinants of CHE in Nigeriabetween 1997 and 2017 sought. Search terms used include household, out-of-pocket,catastrophic expenditure, Nigeria. Primary research on CHE done in Nigeria were selected.StudiesnotestimatingCHEatthehouseholdlevel,onCHEinanimalsornotpublishedinEnglishwereexcluded.

Results:Atotalof13relevantstudiesthatfulfilledthestudyinclusioncriteriawereidentifiedoutof62studiesfound.Tenwerecross-sectionalsurveyswhile3weresecondarydataanalyses.Allthirteen studies reported on the determinants of CHE while eleven of them reported on thequantitative incidence of CHE inNigeria using different thresholds.Out of the 11 studies thatreportedCHE,1reportedCHEof20.7%at>10%totalHHincome.At10%CapacityToPay(CTP)9.6-96.7%HHhadCHE,at40%CTP,3.2%-100%HHsincurredCHE.Onestudyreported8.2%CHEat 5% CTP. CHE was more among the poor, elderly, rural dwellers, private facility utilization,femalegenderandthenon-insuredamongothers.

Conclusion:IncidenceofCHEismarkedamongNigerians.UHCshouldbemadeapoliticalpriorityinNigeriaandcontextuallyfeasiblestrategiestoreduceCHEadopted.Exemptionsforpaymentshouldbeapplied for thoseat-riskofCHEsuchas thepoor,elderlyand ruraldwellers.Formaland informal sectormandatoryprepayment insurancemechanisms shouldutilizeexisting localsocialinstitutionstoincreasecoverage.


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Parallel Session 5-2 Maternal and child health care 2

Socioeconomic correlates and the demand for child healthcare services in Ghana, Kenya and Zambia

EricArthur,KwameNkrumahUniversityofScienceandTechnology Thehealthofthechildisanimportantfactorforproperchildhooddevelopment.Unfortunately,effortsto improvechildhealth inmanycountrieshavenotyieldedthedesiredresultsasmanychildren do not receive appropriate health care when sick, hence contributing to high childmortalityandmorbidityfromavoidablecauses.Toaddressthisproblem,itisimportantthatweunderstand the factors that drive the demand for child health care services. This study,employing the binary and multinomial logistic regression models, examines the effect ofhousehold socioeconomic status on the demand for child health care in Ghana, Kenya andZambiausingdatafromthe2014DemographicandHealthSurveys.Theresultsindicatethatthelikelihood of seeking appropriate health care for the child is higherwhen both parents’makedecisions in thehouseholdcomparedtowhenthewomanalonemakesdecisions.The findingsfurtherindicatethattheoddsofseekingfortreatmentforthechildfallswiththebirthorderandage of the child, but increases with household wealth, insurance status and proximity to thehealth facility. Working women are more likely to demand for child health care than theircounterpartswhoareunemployed.Our results, therefore, suggest that improving childhealthwillneedtheparticipationofbothparentsinthehouseholdonsuchdecisions.Besides,thereisthe need to educate parents on the importance of seeking for appropriate care for all thechildrenbornirrespectiveofthebirthorderandageofthechild.Thereshouldalsobedeliberateeffortstoimprovetheeconomiclotofhouseholdsandencouragethemtoparticipateinhealthinsurance schemes to enable effective utilization of health care services for the child in theeffortstoimprovechildhealthinthesecountries.

Kenyan women’s preferences for place of delivery: A comparative Discrete Choice Experiment between Embakasi North sub-County and Naivasha sub-County, Kenya.

JacklineOluoch-Aridi1,Francis.N.Wafula1,MaryAdam2andGilbertK’okwaro11InstituteofHealthcareManagement,StrathmoreUniversity2AICKijabeHospital

Background:Manysub-SaharanAfricacountriesovertheyearshave introducedpoliciesaimedat removing barriers to access health service utilization including removal of user-fees. TheKenyan Government in 2013 via presidential decree initiated such a policy with an aim ofincreasing access to facility based delivery in an attempt to reverse Kenya’s high maternalmortality ratio. Despite the new policy women continue to choose to deliver their babies athomeandwomenarealsobypassingsmallerprimaryhealthfacilitiesandhavingtheirbabiesattertiary facilities. Health system factors related to place of delivery arewell studied howeverwomen’spreferencesthatdrivethedemandforcertainhealthfacilitiesoverothersarenotwellunderstood. This study aims to fill this research gap by using a discrete choice experiment to


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establish the relative importance of attributes that drive women’s preferences for a place ofdeliverytoimprovetheunderstandingofpatternsofmaternalhealthserviceutilization.

Objectives:Thestudyaimstoexaminewomen’spreferencesforplaceofdeliveryandestablishtherelativeimportanceofattributesofthehealthfacilitiesthatdrivewomentochoosefacilitieswhere they deliver their babies. The study will compare attributes of women in a peri-urbancontext inEmbakasiNorthsub-Countywiththoseinapredominantlyruralcontext inNaivashasub-CountyinKenya.

Methods: The study intends to utilize mixed methods framework incorporating both aqualitativestudyandaquantitativemethodologyknownasDiscreteChoiceExperiment(DCE)todetermine the most important health facility attributes preferred by women when choosingtheir place of delivery. Household characteristics data for women will also be collected via across-sectionalsurvey.

Conclusion: This study hopes to establish the relative importance of health facility attributesvalued bywomenparticularly in the two settings in Kenya and use the information to informpolicy making both at the devolved county units and National Ministry of Health. Thisinformation should be used for resource reallocation to promote health equity and efficientservicedeliverywithinhealthfacilitiesinbothurbanandruralareas.

How secure are primary health care facilities to provide services for the vulnerable population?: Experience of providers in a maternal and Child Health programme

EnyiEtiaba,BenjaminUzochukwu,EnuguUniversityOfNigeria

Background: MaternalandChildHealth(MCH)isapriorityinNigeria.AlthoughmortalityratesdeclinedintheMDGyears;Nigeriadidnotmeettargets4and5.Accesstoservicesremainsoneof key challenges. Abundant literature exists on supply anddemand side barriers to providingand accessing proven effective interventions. However, little literature exists on how securitywithin health facilities affects provision and use of services, especially by vulnerable pregnantwomenfromsocio-economicallydisadvantagedbackgrounds.

TheNigeriangovernment, addressed this throughaprogrammewhichaimed tomitigatebothdemand-andsupply-sidebarrierstoMCHservicesfortheunderservedpopulation.During2012-2015,theprogrammetrainedanddeployedmidwivesandcommunityhealthworkers(CHWs)inprimary healthcare facilities; upgraded infrastructure (including perimeter fencing in somefacilities); provided supplies and financial incentives to pregnant women to access and utilizeservices. A novel group of CHWs; village health workers, were also trained and deployed tomobilisepregnantwomenandassistthemtoaccessservices.

Objective: Aim of the studywas to evaluate the effectiveness of these interventions towardsprovidingequitableaccesstoservicestotheruralandunderservedpopulation.

Methods:Thison-goingstudyemploysaphasedmixed-methodsRealistEvaluationapproachtoassesshowandunderwhatcircumstancesprogrammeworkedtoachieveoutcomesinAnambrastate, southeast Nigeria.We conducted in-depth interviewswith facilitymanagers and healthworkers. Specific programme theories, showing causal pathways of change, have beencontinuouslyvalidatedandrefinedthroughoutdatacollectionandanalysis.

Key Findings: The programme had upgraded facilities and with help of the communityattempted to keep facilities secure, for example through erecting perimeter fences anddeploymentofwatchmen.However,mosthealthworkers felt insecureatnight,due to lackofsecurityguards.Asaresultmosthealthworkerswhowereall femaledidnot feelconfident to


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provideservicesatnight.Thesenseoflackofsecurityhaddetrimentalimplicationsforachievingprogrammeoutcomes,oneofwhichwastoincreasefacilitydeliveriesbyskilledbirthattendants.

Conclusion:Poor securitycontributed to lackof feelingof safetyby thisvulnerablepopulationgroup and this directly influenced provision of round-the clockMCH services in an otherwisewell-fundedandequippedprogramme.Giventhatsignificantproportionofdeliveriesfallduringnighttime,ensuringadequatesecurityatnightwillcontributetoround-the-clockMCHcareandthereforecanhelpaddresstheneedsofmostvulnerablepopulations.

Financing Family Planning Activities Using Domestic Resources at District Level in Malawi

ChristineOrtiz,ThePalladiumGroup-HealthPolicyPlus

Background: Malawi’s Costed Implementation Plan for Family Planning (CIP) guides familyplanning (FP) programming in Malawi, and seeks to increase domestic financing for FP atnational and district level.5In Malawi, decentralization gives District Councils the mandate todevelop budgets that reflect local priorities, including determining which FP activities areimplementedannually.CouncilsarecriticalinearmarkingresourcesforFPactivitiesandreducingpartneranddonordependency.Thisabstractdescribestheprocesses,impactsandlessonslearntfrom an advocacy intervention carried out by the USAID-funded HP+ project, in collaborationwith theReproductiveHealthDirectorate (RHD) in theMinistryofHealthaimedat integratingtheCIPintotheDistrictImprovementPlans(DIP)infourdistrictsinMalawi.

Objectives:TotestadvocacyapproachestoincreasinggovernmentfinancingFPactivitiesatthedistrictlevel.

Methods:RHDandHP+followedamulti-stageapproachthroughnationalandzonalconsultativeworkshopstoprioritizeFPactivitiestobeprogrammedinMalawi.HP+andRHDthenfocusedonfour selecteddistricts,where additionalworkshopsprovidedevidenceon status of sexual andreproductivehealthandFPinthedistrictbasedonnationalsurveyssuchasMICSandMDHS;andbuilding advocacy skills of district teams, which comprised members of the District HealthManagement Team, FP focal person, youth-friendly health services coordinators, and DIPcoordinators.Theyprioritizedhighimpactactivitiesforchangingsexualandreproductivehealthoutcomesinthedistrict.HP+conductedafollow-upworkshoptoassessprogressandtoprovidetechnicalassistance. AftercompletingtheDIPsandtheapprovalofbudgets,areviewmeetingwasconductedtoreviewtheadvocacyprocess.

Findings: District FP coordinators were better advocates to key decision makers on theimportanceofFPforachievingdistrictobjectives.MachingawastheonlydistrictthatallocatedFP funds in their government budget, even though the district had a reasonable number ofpartnerssupportingFPactivitiescomparedtotheothers.

Conclusion: The district health budgets lack resources generally, and district leaders prioritisecurativeoverFP(preventative)services.FPactivitiesarelefttodonorstosupport.Inresponse,HP+hasexpandeditsadvocacyscopetotargetthedistrictcouncils,withthehopeofinfluencingan increasedallocation tohealth in theoverallbudget, so that it reasonablycoversa rangeofhealthneeds,includingFP.

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Factors Affecting Access and Utilization of Child Health Care in Nigeria

RifkatuNghargbu,FederalUniversityLafia

Nigeria has one of the highest under-fivemortality rates in theworld at 128 out of 1000 livebirths.Althoughtheunder-fivemortalityratedecreasedfrom201deathsper1,000livebirthsin2003 to 128 deaths per 1,000 live births in 2013, Nigeria could not achieve the MillenniumDevelopmentgoals(MDGstargetofreducingtheunder-5mortalityto64deathsper1,000livebirths in 2015. The objective of this paper is to estimate the factors affecting access andutilizationofchildhealthcareinNigeriausingDHSdatafrom1990-2013.Logitandmultinomialregressionresultsshowsthatwealth,education,region,mothersageandchildagearethemostsignificant factors affecting child health care access and utilization. Hence child health careutilizationcanbeimprovedifeducationandempowermentprogrammesareenhanced.

Investing in the Midwifery profession in Cameroon: a strategic condition to strengthen maternal health coverage

YvesBertrandDJOUDAFEUDJIO,Sociologist/Lecturer/UniversityofYaoundeIAntoineSOCPA,Anthropologist/Professor/UniversityofYaoundeI Context: In Cameroon, the two decades (80-90) of economic recession were marked by theretreatofthestatewhich,until2012,suspendeddirecttrainingtothemidwiferyprofession(SF),thus abandoning maternity services in the face of a critical shortage of qualified humanresources. All public maternity services in Cameroon must cover a need that requires theavailabilityof5,400midwives(UNFPA2013:6). In2011,thenumberofwomenofchildbearingage (15-49 years) was 4,817,000; the number of births per year was 701,000. However, thedensity of midwives, midwives and obstetricians was only 1.8, indicating a real shortage ofcaregivers (UNFPA, 2011: 60 ). The current ratio estimatesmore than 39,483women for theservicesofasinglemidwife,onemidwifeper5,000livebirths.ThiscrisisintheavailabilityofSFhumanresourcescontrastswiththeworryingepidemiologicalsituationof782maternaldeathsper100,000livebirths(DHS,2011).

Objective: This paper aims to make a situational analysis of the many crises that shape themidwiferyprofessionandcontrastwiththepromisestocombatmaternalmortalityinCameroon.

Methodological and theoretical framework: This communication is a specific aspect of abroader postdoctoral project on the issue of supply and access to maternal health care inCameroon.Inadditiontotheliteraturereview,comprehensiveobservationsandinterviewswereconductedwithmidwiferyproviders,specificallyinruralhealthfacilities.Datacollectioncoveredapproximately 15 peripheral level health structures reasonably selected for case studies. Dataanalysisispartofacomprehensivesociologicalapproach.

Main results: Likemanycountries in theSouth,Cameroon facesaquantitativeandqualitativedeficitofMidwives.AlthoughtheCameroonianhealthauthoritiesarestronglycommittedtothefightagainstmaternalmortality,themidwiferyprofessionisstillverypoorlyorganized,issubjecttointerferencebymanyactorswithverydiverseandcontradictoryprofilesandpractices,whicharenotalwayspartofthefightagainstmaternalmortality.nationalorinternationalstandards.

Main conclusion: In Cameroon, there is an urgent need to invest more in the midwiferyprofessiontohopetostrengthenthecoverageofmaternalhealth.

Keywords:invest,midwife,strategiccondition,maternalhealth,Cameroon.


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Women Empowerment, Spousal Violence and Maternal and Child Health Seeking Behaviors

KwameAnsereOfori-Mensah,Dr.EricArthurKwameNkrumahUniversityofScienceandTechnology Genderbaseddiscriminationhasbeenidentifiedtobeamajorconstrainttoeconomicwellbeingacross countries. This is particularly relevant in developing countrieswhere system is notwelldeveloped to deal with such challenges. In recent years, empowering women and reducinggender-basedviolencehasdominatednationalandinternationalpolicyspaces.Severaltargetsofthe recently launched sustainable development goals are directly or indirectly linked toempowering women. The reason for this is not far-fetched; empowering women has severalpathways to welfare improvement, including education and health. In this study, we seek tounderstand the effect ofwomen’s empowerment and spousal violence onmaternal and childhealthseekingbehaviors.

The research analyzeddataonwomenaged15-49whowere interviewedon spousal violencefrom the 2008 Ghana Demographic and Health Survey (GDHS). A total of 2,442womenweresampledforthepurposeofthecurrentstudy.Tomeasurewomen’sempowerment,wedevelopa composite Women’s Empowerment Index (WEI) using Multiple Correspondence Analysis(MCA)thatincludedfourindicators;householddecision-making,women’seducation,ownershipof land or house and proportion earning cash. Spousal violence was measured by a dummyvariablethattakesthevalueof1ifawomanhaseverexperiencedsomeformofviolenceand0,otherwise.Childandmaternalhealthindicatorsusedinthisstudyincludedeliverycarebyskilledattendants,contraceptiveuse, immunizationandlowbirthweight.Themodelswereestimatedusinglogittechnique.

Theresultssuggestapositiveandstatisticallysignificantrelationshipbetweenspousalviolenceand contraceptive use. This implies that victims of spousal violence were more likely to usecontraceptive. On the other hand, we found empowered women were less likely to usecontraceptives. Therewas a negative and statistically significant relationship between spousalviolenceanddeliverybyskilledbirthattendants.Victimsofspousalviolencewere less likelytouse delivery care from skilled attendants.We also found empoweredwomenweremore lesslikely tobedeliveredbyskilledattendants.Therewasevidenceofstrongnegativerelationshipbetweenwomen empowerment and low birthweight. That is,more empoweredwomen lesslikelytohavechildrenwithlowbirthweight.

These findings indicate that women empowerment and spousal violence have importantimplications for the health of women and their children. It is advocated that an approach toimproving the health of women and children in Ghana incorporate programmes to promotewomen’sempowermentandreducegender-basedviolence.

Parallel Session 5-3 Health behaviours and perceptions

Are NHIS clients served inferior and sub-standard medicines?: Perceptions and factors that influence medicines access and quality under the NHIS in Ghana

DanielKojoArhinful,(1);DanielNanaYawAbankwah(2);IreneAkuaAgyepong(3);


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1:Noguchi Memorial Institute for Medical Research, UniversityofGhana,Legon,Accra,Ghana;2:SchoolofPublicHealth,UniversityofGhana,Legon3:Research and Development Division, Ghana Health Service & Public Health Faculty,Ghana College ofPhysiciansandSurgeons Background TheNationalHealth Insurance Scheme (NHIS) has since its establishment in 2003become an integral part of Ghana's strategy towards the attainment of Universal HealthCoverage (UHC). Increased enrolment and utilization over the years has however beenaccompanied by perceived quality of care issues, lowering confidence and sustainabilitychallengesinthescheme.

ObjectiveAspartofareviewtoinformandintroducereformstoenableitachieveitsstrategicsocialgoals,thispaperpresentstheoutcomeofastudythatexaminedthefactorsthatinfluencemedicinesaccessandqualityundertheNHISandperceptionsthatNHISclientsarebeingservedinferiorandsub-standardmedicinescomparedtononNHISclients.

MethodsThestudydesignusedamixedmethodsapproachinvolvingcrosssectionalexploratoryqualitative and quantitative data collection and analysis techniques comprising focus groupdiscussions,in-depthinterviews,exitinterviewsandaprescriptionsurveyinfour(4)purposivelyselectedregionsinallthreeecologicalzonesofGhana.

Results IssuesaroundmedicinesaccessincludingqualityemergedascontestedtopicundertheNHIS.DelaysinthepaymentofclaimsforservicesrenderedtoNHISmembersonbehalfoftheschemewascitedasamajorfactorthatinfluencesaccesstomedication.Providerscomplainedaboutlowreimbursementcoststhatdoesnottakeaccountofcurrenteconomicandinflationaryconditions so some providers resort to prescribing lower priced generics from less knownpharmaceutical companies. On theother hand the insuredmembers consideredbeing issuedwith prescriptions to purchase them outside and the resort to lower priced generics or“unfamiliar” brands that the non-insured clients receive better quality medicines. However,when this notion was validated using WHO rational use indicators prescription analysis, theresults actually showed that from a medically rational perspective, the insured are receivingmoreappropriatecare.

DiscussionLayandpopularnotionsaboutmedicinestendtoperceiveandinterpretappropriatetreatmentinsettingslikethatNHISinGhanadifferently.InsuredmembersintheGhanaNHISarereceiving more appropriate care than the non-insured because the scheme has become animportantenforcerofrationalprescribingthroughclaimsauditing.

ConclusionSystemicinterrelatedfactorsinfluenceperceivedaccessandqualityuseofmedicinesin the NHIS in Ghana that need to be tackled to improve membership drive, retention andconfidenceinthescheme.

Perceived barriers and facilitators to adherence to antiretroviral therapy among persons living with HIV in the Upper East Region.

GiftyApiungAninanya1,MichaelWombeogo11UniversityforDevelopmentStudies,SchoolofAlliedHealthSciences,P.O.Box1350,Tamale,Ghana

Antiretroviral therapy (ART) suppressesHIV replication anddecreases progression toAcquiredImmuneDeficiencySyndrome(AIDS).High levelsofadherencetoARTarerequiredto improvethequalityoflifeofpersonslivingwithHIVandAIDS(PLHIV).However,littleevidenceexistsonbarriersandfacilitatorstoARTadherenceinGhana.ThisqualitativestudyexaminedbarriersandfacilitatorstoARTadherenceamongPLHIVintheUpperEastRegion.


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Using descriptive phenomenology approach to qualitative enquiry, we conducted five focusgroup discussions (n=31) and ten (10) in-depth interviews with persons living with HIV. Inaddition, twelve in-depth interviews were conducted with health staff. Purposive samplingtechnique was used to select study participants. Colaizzi's descriptive phenomenologyapproachwas adopted and used to code the data with the aid of Nvivo 11 softwarebeforethematiccontentanalysis.

Barriersthataffectedadherencetoantiretroviralmedicineswerelackofnutritionalsupport,sideeffectsofART,occasionaltravels,inadequatesocialsupport,lackofhealthinsurance,accesstotransportation, economic problems, lack of confidentiality, negative attitudes of some healthstaff,queuingupforantiretroviral,non-disclosureofHIVstatusandstigmaanddiscrimination.PerceivedfacilitatorstoARTadherencewereappropriatecounsellingandeducation,provisionofnutritionalsupport,improvedhealthstatusduetoART,theuseofreminderaids,pregnancyandstigma-reductionpolicies.

SeveralfactorshavebeenfoundtohaveanegativeeffectonPLHIVadherencetoantiretroviraltherapy.Nonetheless,itisrecommendedthateffectiveandappropriatecounsellingtechniques,provision of food supplements, stigma-reduction policies and regular training programmes forhealthstaffonHIVcasemanagementcouldhelptoimproveadherencetoantiretroviraltherapyby PLHIV. If all thesemeasures are executed, Ghanawill achieve its aim of having zero AIDS-relateddeathsby2030.

Awareness of Lassa Fever Virus Disease Survey

*IfeanyiNsofor,UgonnaOfonagoro,**BellIhua,*ABUJAEpiAFRIC,**NOIPolls

Background:LassafeverisaviralhaemorrhagicfevercausebytheLassavirus.In2018,Nigeriawitnessed a large Lassa fever outbreak. Consequently, EpiAFRIC in partnership with NOI Pollsconducted another survey to assess Nigerians’ awareness about modes of transmission,symptomsandpreventionof Lassa fever.The samequestionnairewasused forboth the2016and2018surveys.

AimsandObjectives:TheobjectivewastocompareresultsfrombothsurveystodeterminehowNigerians’Lassafeverawarenesschangedbetween2016and2018.

Methods: The survey involved telephone interviews of a random nationwide sample. Onethousandrandomlyselectedphone-owningNigeriansaged18yearsandabove,representingthesixgeopoliticalzonesinthecountry,wereinterviewed.

Keyfindings:AwarenessofLassafevervirusdiseasedroppedslightlyfrom81%in2018to80%in2018.Acrossgeo-politicalzones,theNorth-Centralzoneaccountedforthehighestpercentageofrespondents (88%)whoareawareof theoutbreakof thediseasecompared to89% inNorth-East zone in 2016. ‘Radio’ (40%) topped the list of sources of awareness and ‘television’ wassecond(39%).Incomparison,the2016surveyresultsindicatedthat‘television’(46%)cametops.There is an 8% increaseof residentswhobelieve that keeping their environment cleanwouldpreventbeing infectedbyLassaFevervirus.At35%, therewasnochange in respondentswhosaidthat‘theywillensureallfoodsarecoveredandproperlystored’.At14%,thereisa10%drop-downfrom24%-inrespondentswhosaidtheywouldpreventthediseaseby‘gettingridofratsintheirenvironment’.Sixty-sixpercentofrespondentsstatedthat‘fever’isoneofthesymptomsofthedisease.Thisshowsa3%increasefromthe2016reportresultof63%.Thereisnochangeinthepercentageofrespondentswhoarewillingtoseekmedicalassistance(92%).


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Main Conclusions: Results from the 2016 and 2018 surveys indicate that awareness of LassaFever,aswellasawarenessofmodesoftransmissionandwhattodotopreventthediseaseishigh.Unfortunately,thisdoesnotseemtotranslatetobehaviouralchange.Foodarestilldriedintheopenandpeoplestillexhibitpoorattitudestorefusedisposal.Healthworkersmustobservethestricteststandardsofinfectionpreventionandcontrolprotocolsinhandlingpatientsthataresuspected.Theymustadoptthetestandtreatpracticeespeciallyformalaria.

Exploring the perceived risks and benefits of heroin use among young people (18-24) and service providers in Mauritius: A Qualitative Study

DavidWhite,Quatre-BornesCollectifUrgenceToxida

Introduction:Despite an existing tradition of harm reductionpolicies backed by routine dataandsurveys,existingtoolsdonotcapturetheperspectivesofyoungusersthemselvesontheriskswhich they face when using heroin and harm reduction (HR) services. How such risks areperceived, assessedandacteduponby clients can impactonboth individualdruguseand theeffectivenessofcurrentharmreductionstrategies.

From the traditional economic perspective, the behaviour of individuals is compounded bydecisionsresultingfromthecarefulweighingofcostsandbenefits.Ideally,thisindividualprocessis informed by existing preferences, leading tooptimal decisionswhich are shapedby rationalchoice. This approach, however, struggles to explain illicit drug usewhich is deemed as “riskybehaviour” or “irrational” from a traditional economic perspective. The inductive qualitativeapproach used in this study addresses some weaknesses in the traditional applications ofeconomic theory when confronted with heroin use and assesses how individuals frame theirdecisiontouseintermsofperceivedlossesandgains.

Methods:The sample for this study consisted of 22 individuals, aged 18-24,whowere eitherusingor had recentlyusedheroinand5 serviceproviders.Data collectionmethods includedasystematic literature review and in-depth interviews. The coding framework was revised asthemesemergedandparticipantswererecruitedaccordingly.Cross-caseanalysiswasuseduntilsaturationofthemesoccurred.

Findings: The analysis gradually unveiled howparticipants assessed riskwhilemanaging theirindividual drug use over time. Polydrug use emerged as a recurrent coping mechanismresulting fromchangingdynamicswithintheheroinmarket.Severalvariationswerenotedwithintheinitiationintolong-terminjectingdrugusewhichfurtherhighlightedthechangingnatureoftherisksandbenefitsperceivedbyyoungusersataveryearlystage.Thestudyalsohighlightedsignificant gaps in information among users which encouraged the existence of powerrelationshipscharacterisedbyinformationasymmetry.

Recommendations:The changing nature of the risks incurred by young heroin users impliesthe need to develop second-generationHR strategies specific toMauritiuswhich stratify andreduce risks incurred by individuals (including pregnant women), couples and communities.Qualitativeresearchwhichalsoexplorescontextual rationality and uncertainty can thuscomplement programmatic studieswith in-depthbehavioural-economicinsights,providedtheyareclient-driven.

Red Zone Paramedics– a film about the everyday experiences of an ambulance crew in Cape Town: Using film to develop bottom-up solutions to address violence.


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LeanneBrady,UniversityofCapeTown

PLEASE NOTE: This is a multimedia submission (short documentary film:https://vimeo.com/285241755)

Background:Healthsystemsaredeeplyrootedinhistoricalandsocio-politicalcontexts.In1994,the South African government inherited a deeply inequitable health system and apartheidpolicies created large disparities between racial groups in terms of socio-economic status,occupation,education,housingandhealth.Thesepatternsof inequalityarestillpresenttoday,andexceptionallyhighlevelsofviolencepersistingeographicareasthatmirrorapartheidspatialpatterns.Althoughoutcomesforkeyissues(suchasmaternalandchildhealth)areimprovinginSouth Africa as a whole, violence remains endemic and in theWestern Cape specifically, theratesofviolenceareontheincrease.ThisposesasignificantchallengefordeliveringPHCforall,and emergency medical services in this context have specific challenges. With an increasingnumber of attacks on ambulance crews since 2012, the safety of paramedics has become anationalpriority.

Methodological approach (action research in HPSR): Violence is connected to SustainableDevelopmentGoals3(GoodHealth)and10(ReducedInequality)andgivenitscomplexnature,requires new research methods to support the community-based interventions required toaddressit.IntheWCDOH,filmispartofthprocess.Historically,addressingviolencewasseenasthe responsibility of the criminal justice system. However, the Western Cape Department ofHealth (WCDOH) is currently implementing a range of evidence-based inter-sectoralinterventions that takeapublichealthapproach toviolence,andseek toaddress thecomplexsocialfactors(atthelevelofsociety,community,familyandindividual)thatinteracttoproduceviolence.

‘RedZoneParamedics’isafilmaboutanambulancecrewworkingthenightshiftonNewYearsEveinMitchellsPlain,aparticularlyviolentpartofCapeTown.Thefilmfollowsthecrewastheyrespond to emergencies. With long granular shots winding through darks streets whilenavigating thevisceralcomplexitiesofdeliveringhealthcare– this isa filmabout theeverydayexperiencesoflifeontheroad.

Sub-themesignificance:Community-ledandparticipatorygovernanceinitiativesareakeypartofthisstrategy.Paramedicsarethecommunityhealthworkers(CHWs)ofemergencycare.Theydeliver healthcare to people in their homes, at the time when they need it most. Improvingneighborhood safety requires new models of community engagement to develop sharedgovernance and bottom-up accountability frameworks, to achieve the goal of deliveringemergencyhealthcareforall.

Purpose/Objective: WCDOH uses the film to facilitate public conversations with community-basedinter-sectoralgroupsaboutissuesofviolence,andtoco-produceappropriatestrategies.

(NOTE:Thefilmis16minuteslong)

Perceived barriers to accessing female community health volunteers’ services amongst ethnic minority women in Nepal: a qualitative study

SaritaPanday*,PaulBissell**,EdwinvanTeijlingen****StanfordUniversity**SchoolofHumanandHealthSciences,HuddersfieldUniversity***FacultyofHealth&SocialSciences,BournemouthUniversity


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Background:Disparities in health service utilisation by ethnicminority groups have beenwelldocumented in Nepal, yet much less is known about the factors that contribute to thesedisparities.Oneway that theNepali governmenthasattempted toaddress thesedisparities isthroughmobilisingcommunityhealthworkers,knownasFemaleCommunityHealthVolunteers(FCHVs).FCHVsprovidebasicmaternalandchildhealthcareservicesacrossNepaland inotherresourcepoorcountries,yet,womenfromethnicminoritygroupscontinuetounderutilisesuchservices. This study sets out to explore perceived barriers to accessing maternal and childhealthcareservicesamongstethnicminoritygroups.

Methods: Villages were selected in two different geographical locations (the hill and terairegions- flatland bordering south India) with varying degrees of access to local healthcarecentres.DatawascollectedbetweenApril2014andSeptember2014usingqualitativemethods.Semi-structuredinterviewswereconductedwithtwentyFCHVs,26womenserviceusersand11paid local health workers. In addition, 19 FCHVs participated in four focus group discussions.Datawereanalysedthematically.

Results:Serviceusersfromethnicminoritycommunities,Dalits,Madhesi,Muslim,ChepangandTamang, underutilised FCHVs’ services, including biomedical services. The following four keybarriers to accessing maternal and child healthcare services by ethnic minority communitieswerereported:a)alackofawarenessofhealthcareservices;b)traditionalbeliefsandhealthcarepractices; c) low decision-making power of women; and d) perceived indignities experiencedwhenusinghealthcentres.

Conclusions: We conclude that community health programmes should focus on increasingawareness of the importance of healthcare services amongst ethnic minority groups and theprogrammeshouldinvolvefamilymembersandtraditionalhealthpractitioners.BoththeFCHVsand local healthcare providers need training and educational support to develop effectivecommunication skills for delivering context specific and respectful care to these groups if wewanttoachieveuniversalhealthcarecoverageformaternalandchildhealth.

Perspectives of males on utilization of health services: important stakeholder in achieving household sustainable health

Author:Agbo,H.A1,2[MBBS,FWACP,MSC,MPH]DepartmentofCommunityMedicine,1JosUniversityTeachingHospital/2UniversityofJosCo-authors:AkosuT.J[MBBS,FWACP],1,2AdahG[MBBS]1 Introduction:HealthofthecitizenarebeenpromotedbydifferentgovernmentthroughdiversemethodsinNigeria,howevertheexpecteddesiredoutcomesisstillamirage.Manyreasonsmaybe attributed such as lack of resources, illiteracy, poor health behaviours which may beinfluenced by lack of male participation in household health seeking behavior. Maleinclusiveness in household decision making is an essential component if the needed healthoutcome is envisaged especially in Africa where cultural/traditional practices which bestowunlimitedpowertothemalecounterpartsarestillheldinhighesteem.

Studies have accrued to the importance of male inclusiveness at promoting family planninguptake,deliveryservices,prompthealthdecisionmakingetc.Mostrecently,thegrowingneedto encourage male participation in household health have being promoted. A pilot study onobserved poor health seeking behaviours of mothers in a densely populated semi urbancommunityinJosPlateaustatenecessitatedthisstudy.

Aimsandobjectives:Thestudyassessedthemalewillingnesstoencouragehouseholdutilizationofhealthservices,theirknowledgeofthebenefitsofutilizinghealthservicesandchallengestoutilization.


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Methods:StudywasconductedatNassarawaward,Jos,Plateaustate.Havinghadpermissionforthe study by the head of a religious group (Imam of a mosque) where virtually all the malehouseholdheadsattend for theirmandatorymorningprayers,asemistructuredquestionnairewas administeredaidedby two trainedassistantsover threedays to all adultmalehouseholdheadswhoconsentedtobestudied.

Findings: One hundred and sixty sixmarried household heads participated, 23(13.9%) had noformal education, 95(57.3%) practiced polygamy, 52 (31.3%) had more than 10 householdmembers.Ninetyseven(58.4%)indicatedtheirwillingnesstoencouragehouseholdmemberstoutilizehealthservices,102(61.4%)hadagoodknowledgeofaccruedbenefits,36 (21.7%)wereskeptical of itshigh cost, 72 (43.4%) indicated longhoursofwaiting, 16 (9.6%) feltwives takeundueadvantageofhospitalvisitsforotherventures.

Conclusion:Unaffordabilityof servicesand longhoursofwaitingwere someof the challengesidentified.Insuchahighfertilitysetting,communityhealthinsurancewillalleviateout-of-pocketspendingonhealthtopromoteutilization.

Patient satisfaction and clinical quality in South Africa’s public primary healthcare

DumisaniHompashe,ProfRonelleBurger,ProfUlfGerdtham,DrAnjaSmith,CarmenChristianStellenboschUniversity Background:Patientsatisfactionsurveyshavegainedtractionasvaluablesourcesofinformationfordevelopingeffectiveremediesforqualityhealthcareimprovement.Thereexistsevidenceofcorrelation between highly satisfied patients and continuity of care, with satisfied patientstending to comply better with treatment. However, there is concern that patient satisfactionratingsareinfluencedbypatients’personalpreferencesandexpectations.Anothershortcomingofpatientsatisfactionsurveysistheexistenceofpositivitybias,withpatientstendingtorespondoverlypositiveduetosocialdesirabilitybiases.Yetthesesurveysprovideaninexpensivewaytopolicymakersofobtainingsignalsofhealthsystemperformance.

Inmeasuring the quality of healthcare, studies are increasingly focusing on the nature of theclinical encounter between the healthcare worker and patient. One way of obtaining moreobjectiveinformationontheencounteristhroughstandardisedpatient(SP)visits.

Aim:Theaimofthisstudywastoexploretheadvantagesandlimitationsofpatientsatisfactionmeasures at primary healthcare level by analysing the relationship between reported patientsatisfactionandmeasuresofclinicalquality.

Method:We conducted SP visits and patient exit interviews in primary healthcare facilities intwo South African provinces for three health areas: tuberculosis, hypertension andcontraception. The study captured data on the clinical quality of 464 primary healthcare SPconsultations and 1064 patient exit interviews. This allowed us to compare the satisfactionratingsofSPstotheclinicalqualityoftheirencounters.Wealsocomparedthesatisfactionofrealpatients as collected through exit interviews tomore objective self-reported clinicalmeasuresfromtheirvisits.

Key findings: The satisfaction rating of standardised patients corresponded to clinical qualitymeasures in facilities.Patientsatisfaction fromexit interviewsshowedsocialdesirabilitybiasesespecially in areas in which the socio-economic status was low. While the sample is notnationally representative, it couldbeconsideredas indicativeof theexperiencesofpatients inmetropolitan areas (most likely an upper limit to these experiences compared to rural areas),whileitalsoprovidesanindicationofthelimitationsofpatientsatisfactionmeasures.


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Conclusion: Findings from the study add to existing literature on patient satisfaction as ameasureofqualityandprovidesuggestionsforfutureresearch.

Keywords: Patient satisfaction measure, clinical quality measures, standardised patientapproach,SouthAfrica

Outreach as A Tool to Prevent Chronic Diseases and Create Demand for their Care in Uganda: Cost-Effectiveness and Community Perceptions

KennethR.Katumba1,DominicBukenya1,ArthurNamara1,GiuliaGreco1,2,3,JanetSeeley1,2PatrickTenywa11Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & TropicalMedicine(MRC/UVRIandLSHTM)ResearchUnit,EntebbeUganda2LondonSchoolofHygieneandTropicalMedicine,London,UnitedKingdom3SchoolofEconomics,MakerereUniversityKampala,Uganda

Background: ChronicDisease (CD)management is still neglected in Low IncomeCountries. InUganda, though highly prevalent, CDs are characterized by low public knowledge, prevention,screening, and budget spending. Our aim was to demonstrate community outreach as animportantandcost-effectivetooltobringawarenessonDiabetesandHypertension(DM/HT)tothegeneralpopulation.

Methods:Ourstudywasamixed-methodsstudynestedintheHealthSystemStrengtheningforChronic Diseases (HSS-CD) project, a 4-year collaborative research programme between theMRC/UVRIandLSHTMUgandaResearchUnit;MwanzaInterventionTrialsUnit;LondonSchoolofHygieneandTropicalMedicineandtheMinistriesofHealthofUgandaandTanzania.

Toelicitcommunityperceptions,In-DepthInterviews(IDIs)andFocusGroupDiscussions(FGDs)evenly distributed into intervention and control arms were carried out across sexes, withpurposively-selected participants. IDI participantswere selected from a 1-2 KM radius aroundsampledhealthfacilitieswhiletheFGDsparticipantswereselectedfroma1KMradius.

To estimate cost-effectiveness, all health facilities randomized under theHSS-CDprojectwereincluded. We used the ingredients approach to estimate the incremental economic cost ofproviding outreach services towards DM/HT for 1 year, with costs collected from projectaccountsandinterviewswithhealthfacilitystaff.Weestimatedoutcomesasthetotalnumberofpeoplescreenedpositivethatwasregisteredbythehealthfacilities.

Results:MajorityoftheIDIsandFGDsparticipantsintheinterventionarmreportedmoresignsandsymptomsofHT/DMthanthoseinthecontrolarm.Almostallinterventionandcontrolarmparticipants reported several important ways of creating awareness, non-specific to DM/HT.They explained that awareness about DM/HT could be created through facility-based healtheducation.

Onaverage,HCIIsandHCIIIsintheinterventionarmcarriedout19and21outreachvisitsintheyearrespectively.74%ofthetotaloutreachcostswassalarycosts,21%transportcosts,and5%capital costs. The averageunit cost peroutreach visitwasUSD13 and16 forHCIIs andHCIIIsrespectively. Theaverageannual costperpatient screenedwasUSD1.3and1.1 forHCIIs andHCIIIsrespectively.TheICERforprovidingcommunityoutreachservicescomparedtoasituationwhereoutreachserviceswerenotprovidedwasUSD1.

Conclusion:We demonstrated that outlook can be an important and cost-effective way tocreateawarenessonchronicdiseasesandincreaseutilizationoftheirservicesamongthegeneralpopulation.


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Voices from the Middle belt of Ghana on UHC for all – Participation and Perceptions of Older Persons on Social Health Insurance Program utilizing a mixed method approach.

DorisOttie-BoakyeSarpong,RegionalInstituteforPopulationStudies,UniversityofGhana-Legon,Accra

Aim:Toexplore theextentofolderpersons’participation,perception leveland reasonsaboutGhana’sNationalHealthInsuranceScheme(NHIS)inAshantiregion.

Objectives: Social health insurance is an extension to social protection explicitly recognized intheAgenda2030,thoughitwasmissingundertheMDGs.Thereisanincreasingfocusonhealthcare financing inmany developing countries as part ofmeeting the Sustainable DevelopmentGoals, especially Goal 3. Although, many developing countries are gradually experiencing anincreasing ageing population, there is much less available evidence of older persons’participationandperceptionsrelatedtosocialhealth insuranceprograms.Ghana implementedthe pro-poor National Health Insurance Scheme almost a decade and half ago to promotefinancialaccesstohealthcareamong itscitizens.Embedded inthesocial insuranceprogramisthe Exempt policy for the vulnerable including older persons and the indigent. This papertherefore provides insights into the extent of older persons’ participation and perceptionsrelatedtotheNHISintheMampongMunicipalityoftheAshantiRegioninGhana.

Methods:Atriangulationmixed-methodconstitutingacrosssectionalhouseholdsurveyof400olderpersons(60+years)andeight focusgroupdiscussionswerecarriedout in2017.Statisticaltechniques usedwere descriptive, Exploratory factor analysis and the thematic analysis. StataandtheAtlas-tisoftwaresweretoolsusedfordataanalyses.

Key findings: The mean age was 73.7years.More than half were females and rural dwellersrespectively.One-thirdhadnoformaleducation.Two-thirdswereengaged inagriculture.One-fifthhadnoformofcaregiving.One-thirdreportedtohavenon-communicablediseases.While60%wereenrolleesofNHIS,about30%wereformerschememembersand8%hadneverbeenregistered.Fifty-ninepercentachievedinsurancemembershipasExemptbyage,indigentorasabeneficiary of Livelihood Empowerment Against Poverty program. With Cronbach alphacoefficient of 0.90 and a significant Bartlett’s Test of Sphericity generating perception indexresultedin58.5%and32.0%havingmoderateandbadperceptionaboutNHISrespectively.Theprovision of unsatisfactory nature of service, technological challenges due to poor internetconnectivity, extortions, promotinghealth care accessibility andutilizationbut reservationsonspecifichealthservicesofferedat thepointofhealthcareutilizationwerecitedreasonsabouttheprogram.

Conclusion:AddressingidentifiedchallengesandintegratingtheviewsoftheelderlyinNHISarecrucial in promoting participation, reducing catastrophic health payments and ensuring theprovision of satisfactory services from providers in securing UHC for all especially to olderpersons.


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Parallel Session 5-4 Health technology assessments

Health technology assessment capacity at national level in sub-Saharan Africa: a survey of stakeholders

DrSamanthaHollingworth,SchoolofPharmacy,UniversityofQueensland,AustraliaHollingworthS,GadM,WinchA,FraserJ,RuizF&ChalkidouK:iDSI,ImperialCollegeLondon BackgroundHealthtechnologyassessment(HTA) isaneffectivetooltosupportprioritysetting(PS) in health atmultiple decision-making levels. Stakeholder groups need to understandHTAappropriatetotheirroleandtointerpretandcritiquetheevidenceproduced.TheInternationalDecision Support Initiative (iDSI) has been working in sub-Saharan Africa (SSA) since 2013 todeveloplocalcapacityandsupportcountriestoimplementrobustHTAprocesses

Aim To assess the current health system priorities and policy areas of demand for HTA, andidentifygapsindataandskillstoimprovethetargetingofcapacity-buildinginSSA.

MethodsWe revised an existing iDSI cross-sectional survey and delivered it to 357 recipientsthroughexistingnetworks inSSA (e.g. iDSI,AfHEA).Wetargetedpolicymakersand thosewhoinformpolicydecisionsatnationalandsub-nationallevels;andalsothosewhohaveaninterestinhowHTAcanimproveprioritysettinginhealth, includingpotentialsuppliersofHTA-relevantdata.Weanalysedresponsesandexploredkeythemes.

KeyfindingsTherewere51respondents(responserate14%)workinginmostlyuniversitiesandministriesofhealthacross14countries.HTAwasconsideredanimportantandvaluablePStoolwithakeyrole inthedesignofhealthbenefitspackages(HBP),clinicalguidelinedevelopment,andserviceimprovement.Medicineswerethetechnologymostidentifiedasbeingacriticalareafor undertakingHTA (followed by vaccines and public health programs). especially because oftheirhighcostsandabilitytoaddressmajordiseaseburdens.TheuseofHTAtoaddresssafetyissues (e.g. low quality medicines) and value for money concerns was seen as particularlyimportant, perhaps reflecting problems in SSA relating to service quality and efficiency. TheperceivedavailabilityandaccessibilityofsuitablelocaldatatosupportHTAvariedwidelybutinmany instanceswas considered inadequate and limited. Respondentsnoted a strongneed fortraining support in research methodology and data gathering for HTA evidence. The mainlimitations were a low response rate (most responses from Ghana and Nigeria) and thatrespondentswereself-selected.

Conclusions The initial survey across the sub-Saharan African region was successful in raisingawarenessofHTAasatool forprioritysettingand identifyingkeygaps indataandcapacity.Amore tailored and expansive survey can now be developed by iDSI around the key themesidentifiedinthisinitialsurveytotailorengagementstrategiesandtargetcapacitybuilding.

The impact of mobile clinics on increasing access to quality health care: the case of mobile vans outreach services in Ghana

SamuelKabaAkoriyea,AccraGhanaHealthService

TheGovernmentofGhanahasadoptedtheuseofmobileclinicstoenabletransformitshealthsystems with the goal of improving access and promoting equity towards the attainment ofUniversal Health Coverage and Primary Health Care. Using theMobile Vans Outreach Service(MVOS)ensurecomplementaryandreliableservicedeliveryofspecializedcareandroutinebuttargeted services to address epidemics such as cholera, provide routinehealth checks etc. to


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rural, remote, urban slum, economic migrants and other populations with limited access tohealthcareandservices.ThisevaluationreviewtheimpactofMVOSbytheGhanaHealthServicetoimproveaccesstohealthcareandservicesinGhana.

ThisimpactassessmentisanevaluationofroutinedataandservicesprovidedunderthemobileclinicunitattheGhanaHealthServicefrom2015to2017infiveregions.Itassessedtherecordsof the patients, van, outreach activities and requests from institutions and the public to drawlessonsforimprovements.

PreliminaryassessmentofroutinedatafromtheGhanaHealthServiceInstitutionalCareDivisionontheimpactofmobileclinicsusingthemobilevanoutreachesshowsitssignificanceinreachingtargetedpopulationfacinggeographical,financial,structuralandculturalbarrierstohealthcare.Since2013, theeightmobileclinicshavebeenusedtoprovidespecialisedservicessuchasEarNoseandThroat(ENT),eye,dentalandgeneralmedicineand10biomedicalmaintenancevansusedtosupportseveralruralclinic.

From2015,themobileclinicshaveattendedto42,514patientsinfiveregionsprovidingdental,eye,otorhinolaryngologyandgeneralmedicalscreeningandtreatments.Theteamalsoconducthealthpromotionandpreventive serviceswhilepartneringwith theNationalHealth InsuranceSchemeto registerandrenewtheirmembers.Overall, themobilevanoutreachservices haveimproved access to healthcare for hard to reach populations and created rapid response tooutbreaks and emergencies as well as support for rural clinics and large group meetings orneglectedpopulations suchas schools,prisons, political rallies, footballmatches,marketdaysandchurchconventions.

The challenge, however, is the limited number of vans available to meet outreach demands,maintain and stock up the vans. This review concludes by recommending the potential ofimproving the use of mobile clinics as an alternative to increasing access to general andspecialised services inGhana. It hasbeen significant inmeeting theneedsof populations thatwouldnormallytobereachedwhenusingfixedfacilities.Hence,theneedtoimprovetheuseofmobile van outreach services by having a dedicated team of health workers, resources andfunding to improve their service inorder toachieve theUHCandPHC fora sustainablehealthsystem

Strengthening Health Technology Assessment (HTA) Systems for Universal Health Coverage in Africa: How can HTA improve equity, access and quality of healthcare services?

KimMacQuilkan,IndependentPublicHealthConsultantLumbweChola,HealthEconomist,PaloHealthConsulting,Johannesburg,SouthAfricaTommy Wilkinson, Health Economist, School of Public Health and Family Medicine, University of CapeTown,SouthAfrica

BackgroundEnsuringaccessible,goodqualityhealthforall,whileprovidingfinancialprotection,especiallytothemostvulnerableofsociety,demandsstrongsystems.Difficultdecision-makingand trade-offs are inevitable in resource-constrained settings, but it is crucial that these arefacilitated within well-governed systems encouraging accountability, standardisation andtransparency.Amongstthetoughestofdecisionsarethosearoundhealthcarebenefits.Althoughexplicit rationingof servicesandentitlements is inherentlydifficult, thealternative is rationingthatoccurspassivelyoftenimpactingaccessforexample.PassiverationingcanthusbeacriticalbarriertothegoalofUniversalHealthCoverage(UHC),forwhichaccessisacriticalelement.AHealth Technology Assessment (HTA) system can provide tools, structures and processes tofacilitatedecision-makingforhealthcareserviceprovisionandfacilitateprogresstowardsUHC.


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AimsandobjectivesThisresearchwillaimtoprovideinsightsforAfricancountriesdevelopingorintending to develop HTA systems by presenting: 1) A general overview of HTA and priority-setting;2)HowHTAsystemscanimproveprogresstowardsintermediateobjectivesandgoalsforUHC; 3) An overview of the development of HTA systems in Africa; and 4) Key enabling andconstrainingfactorstostrengtheningHTAsystemswithinthecontextofUHC.

MethodologyA literaturereviewofpublishedandgrey literaturewillbeconductedto fulfilallfour objectives. In particular, theWorldHealthOrganization’s healthcare financingdescriptionmodel outlining functions (funding, pooling, purchasing, benefits), intermediate objectives(equity in resource distribution, efficiency, accountability/transparency) and goals of UHC(access,qualityandfinancialprotection)6willbeutilisedasaframeworktoguidetheanalysisofliteraturetofulfilthesecondobjective.

Conclusion It is of utmost importance thatweprotect andendeavour to enshrinehealth as ahuman right, UHC is one potential platform for enabling this. Strong integrated HTA systemscouldfacilitateprogresstowardsspecificUHCintermediateobjectivesandgoalsforcountriesinAfrica,helpingtofacilitateHealthforAll.

The Price Impacts of the Introduction of South Africa’s Tax on Sugar-Sweetened Beverages

NicholasStacey,IjeomaEdokaJohannesburg,UniversityoftheWitwatersrandShuwenNg,UniversityofNorthCarolina

Background: In response to a severe and growing burden of obesity and diet-related disease,SouthAfrica,asofApril2018,hasjoinedanumberofLMICcountriesinintroducinganexcisetaxon sugar-sweetened beverages (SSBs). SSBs are linked to the onset of obesity, diabetes, andothermetabolicconditions.TheprimarypathwaythroughwhichSSBtaxesarehypothesizedtoincentivizedecreasedSSBintakeisthroughincreasedretailSSBpricesconsumersfacewithataxinplace.

Aims: This study aims to estimate the impact of the introduction of South Africa’s tax on theretailpricesoftaxedandun-taxedsoftdrinks.

Methods: This study draws on non-alcoholic beverage price data collected by South Africa’snationalstatisticalagencyonamonthlybasisfromJanuary2016throughJuly2018fromapanelofretailoutletsinurbanareasofSouthAfrica(N=36,231).AllpricesareinSouthAfricanRands(ZAR) per litre and are deflated to 2016 ZAR using the consumer price index to account forinflation.Apre-postregressionstrategyisadoptedthatincludesprovince-andtime-periodfixedeffects, with regressions estimated separately by beverage category with real prices as theoutcomeofinterest.

Findings:Amongtaxedbeverageswefindanaverageincreaseinpriceof0.97(0.59–1.36)ZARper litre on carbonatedbeverages and2.70 (0.49– 4.92) ZARper litreon liquid concentrates.Whilstamonguntaxedbeverages,we seeno statistically significant change inpriceonbottledwater(-0.66–0.24)and100%fruitjuices(-0.22–2.12)posttheintroductionofthetax.

Conclusion:SouthAfrica’srecentlyintroducedtaxonsugar-sweetenedbeveragesresultedinanincrease in the prices of taxed beverages,while untaxed beverage prices’ did not change in astatisticallysignificantsense.ThisisincreaseinthepriceofSSBsandincreaseinthepriceofSSBs

6 Kutzin, J. 2013. Health financing for universal coverage and health system performance: concepts and implications for policy. Available: http://www.who.int/bulletin/volumes/91/8/12-113985/en/


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relative to healthier options could incentivize healthier beverage consumption and reducedbeverage-sugarintake.

Strengthening Health Technology Assessment Systems in the Global South: A Comparative Analysis of the HTA journeys of China, India and South Africa.

KimMacQuilkan1, Peter Baker2, Laura Downey2, Francis Ruiz2, Kalipso Chalkidou2, Shankar Prinja3, KunZhao4,ThomasWilkinson5,AmandaGlassman6,KarenHofman7

1.PriorityCostEffectiveLessonsforSystemStrengtheningSouthAfrica(PRICELESSSA),Schoolof PublicHealth,UniversityofWitwatersrand,FacultyofHealthSciences,Johannesburg,SouthAfrica.2.GlobalHealthandDevelopmentGroup,InstituteofGlobalHealthInnovation,ImperialCollegeLondon,London,UnitedKingdom.3. School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER),Chandigarh,India4. DivisionofHealthTechnologyAssessmentandPolicyEvaluation,ChinaNationalHealthDevelopmentResearchCenter(CHNHDR),MinistryofHealth,Beijing,China5.SchoolofPublicHealthandFamilyMedicine,UniversityofCapeTown,SouthAfrica6.CenterforGlobalDevelopment,WashingtonDC,UnitedStatesofAmerica7. PriorityCostEffectiveLessonsforSystemStrengtheningSouthAfrica(PRICELESSSA),Schoolof PublicHealth,UniversityofWitwatersrand,FacultyofHealthSciences,Johannesburg,SouthAfrica.

BackgroundResourceallocationinhealthisuniversallychallenging,butespeciallysoinresource-constrainedcontextsintheGlobalSouth.Pursuingastrategyofevidence-baseddecision-makingandusingtoolssuchasHealthTechnologyAssessment(HTA),canhelpaddressissuesrelatingtobothaffordabilityandequitywhenallocatingresources.ThreeBRICSandGlobalSouthcountries,China, India and South Africa have committed to strengthening HTA capacity and developingtheir domesticHTA systems,with the goal of getting evidence translated into policy. ThroughassessingandcomparingtheHTAjourneyofeachcountryitmaybepossibletoidentifycommonproblemsandshareableinsights.

AimsandobjectivesThiscollaborativepaperaimedtoshareknowledgeonstrengtheningHTAsystemsintheGlobalSouthtopromoteevidence-baseddecision-makingby:Identifyingcommonbarriers and enablers in three BRICS countries in theGlobal South; and Exploring how South-SouthcollaborationcanstrengthenHTAcapacityandutilisation.

MethodologyA descriptive and explorative comparative analysiswas conducted comprising aWithin-CaseanalysistoproduceanarrativeoftheHTAjourney ineachcountryandanAcross-CaseanalysistoexplorebothknowledgethatcouldbesharedacrosstheGlobalSouthandanypotential knowledge gaps. All three countries are part of a global network, the InternationalDecisionSupportInitiative(iDSI),whichprovidesaplatformforknowledgesharingandcapacitybuilding to support evidence-based priority-setting and decision-making. The development ofthe paper involved experts from each country in order to provide the most pragmatic andappropriateinsights.

Results Analyses revealed that China, India and South Africa share many barriers tostrengtheninganddevelopingHTAsystemssuchas:1)MinimalHTAexpertise;2)Weakhealthdata infrastructure; 3) Rising healthcare costs; 4) fragmented healthcare systems; and 5)significant growth in non-communicable diseases. Stakeholder engagement, andinstitutionalisation of HTA were identified as two conducive factors for strengthening HTAsystems.

ConclusionChina,IndiaandSouthAfricahaveallcommittedtoestablishingrobustHTAsystemstoinformevidence-basedprioritysettingandhaveexperiencedsimilarchallenges.Engagement


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amongcountriesoftheGlobalSouthcanprovideasupportiveplatformtoshareknowledgeonstrengtheningHTAsystemsthatismoreapplicableandpragmatic.

This paper was produced as part of iDSI (www.idsihealth.org), a global initiative to supportdecisionmakersinpriority-settingforUHC.TheworkreceivedfundingfromBill&MelindaGatesFoundation (grant OPP1087363, “Establishing Priority Setting Institutions in DevelopingCountries”),theUKDepartmentforInternationalDevelopment,andtheRockefellerFoundation.The funders had no role in study design, data collection and analysis, decision to publish, orpreparationofthemanuscript.

Parallel session 5-5 Mental health issues

Promoting Access to Mental Health Care Services using community structures such as Traditional Mental Health Centers in Ghana

*Gina Teddy, **Wendy Abbey, ** George Owoo: *Ghana Institute of Management and PublicAdministration,**HumanRightsAdvocacyCentre

AccesstomentalhealthcareandservicesinGhanaisproblematicrequiringcollaborativeactionamong multiple actors to improve quality of care, reduce inequity, inaccessibility and socialexclusionforthoseindesperateneedoftheservice. It isestimatedthat2.8millionpeople livewithmentaldisability inGhana,yet lessthan2%accessmentalhealthservices.Thesystematicchallengesinprovidingmentalhealthservicescutsacrossthecountryleadingtotreatmentgapofabout98%. There is limited trainedhumanresources,poorbudgetaryallocation leading toacutefinancialconstraints,acute logisticalanddrugshortage,hugedisparities intheallocationoffacilities,congestionsatthefacilities,highstigmaandlackofinformationformentalhealth.

ThechallengeofstrengtheningmentalhealthservicesinGhanarequiremulti-sectoralapproachandcollectiveleadershiptoharnessresourcestoenableinnovativelybridgetheaccessibilitygapin service provision. Yet, key stakeholders are not effectively collaborating to harness theirlimitedresourcestowardsserviceprovisionorusingcommunitysystemstomobilizesupportformentalhealthservice.Thisstudyanalyzethe impactof failedcollective leadership inprovidingmentalhealthservicesinGhana.

Usinganexploratoryapproach,abroaderstudywasconductedacrosssixregionsinGhanausingbothqualitativeandquantitativemethodstogenerateprimaryandsecondaryinformationfromkey stakeholders on promoting access to quality mental health services in Ghana usingTraditionalMentalHealthCentres(TMHCs)andothercommunitysystems.

The study’s preliminary findings shows that despite the systematic challenges associatedwithmentalhealthcareandservices,thereisnocultureofcollectiveleadershiptoenablemaximizethe limited resources, complement each actors efforts ormobilise key actors for collaborativeactionbetweentheformalandinformalsectortoimprovementalhealth.TheMentalHealthActand other policy frameworks are not also addressing this fundamental challenge ofmanagingmultiple actors. Key actors areworking stillworking in silos, duplicating someof their efforts,despite the range of capacities, expertise and motivation available to address the problemsrelated tomental health care and serviceprovision.Weare advocating for theMentalHealthAuthoritytoprovidestewardshiptowardscollectiveleadershipculturetoenablepulltheeffortsofactorssuchastheGhanaHealthService,ChristianHealthAssociationGhana,NGOs,Donors,


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CommunitySystemsliketheTMHCsandleadersforstrategicimplementationtoimprovementalhealthinGhana.

Promoting Access to Mental Health Care Services using community structures such as Traditional Mental Health Centers in Ghana

*Gina Teddy, **Wendy Abbey, ** George Owoo: *Ghana Institute of Management and PublicAdministration,**HumanRightsAdvocacyCentre

Ghana,likemanydevelopingcountriesisrecognizedformakingsignificantstridesattheendoftheMillenniumDevelopmentGoals. Yet, very littlewas achieved inmental health to improveaccess and quality of care leading to inequity, inaccessibility and social exclusion for those indesperate need ofmental health services. Despite an estimated 2.8million people livingwithmentaldisorderinGhana,lessthan2%accessmentalhealthservices.Thesystematicchallengesin providing mental health services cuts across administrative levels of service provisionthroughoutthecountryleadingtotreatmentgapofabout98%.

Traditional Mental Health Centres (TMHC) are community systems that complements formalmental health services. Yet, there is a general lack of awareness and understanding of thepractices, services, management, regulations, rights and responsibilities in Ghana. This studyexplores the role of TMHCs in providing mental health services to complement the gaps inservice delivery and the critical role of community systems in achieving universal healthcoverage.

ThisexploratorystudyisbeingconductedacrosssixregionsinGhanausingbothqualitativeandquantitative methods to generate primary and secondary information from communities andTMHCs while advocating for mental health improvements and collaborative provision acrosscommunities.

ThestudyrevealedextraordinarybarrierstoaccessingmentalhealthservicesinGhanaleadingtoinequalityandsocialexclusionofpersonwithmentaldisorder.Challengesassociatedtotheuseofmentalhealthservices isattributedto lackof information,stigmaassociatedwithutilizationmentalhealthservices, inadequateresourcesandtheperceived inabilitytomeetsocio-culturalneeds for mental disorders. Preliminary findings revealed the significant role of TMHCs ascomplementing formalhealth services inGhana.TMHCsdealswith theperceivedspiritualandphysicalcausationofmentaldisorderledbytheprayercamps,traditionalhealers,herbalistsandspiritualtreatmentscenters.Yet,therewaslittleornoregulationsfortheirfunctions,practices,services and quality of care leading towidespread convictions of abuses andmistreatment ofpeoplewithmentaldisorderseekingtheservicesofTMHCs.

Thisstudyconcludesbyadvocating foramulti-sectoralapproachbycommunities, researchers,NGOsandtheMentalHealthAuthoritytorecognize,support,standardize,regulate,developandimprove the work of TMHCs in Ghana.We emphasis improving access and quality of care tomake TMHCs responsive in providing dignifyingmental health services for improved access tocare. Policy lesson from this study will inform knowledge, practices, regulation and policiesguiding the practices of TMHCs across communities in Ghana to create a vibrant communityhealthsystem.

Subjective social inequalities in depression: a decomposition analysis for South Africa

ChipoMutyambizi,Gauteng,HumanSciencesResearchCouncil


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Background Inequalities inmentalhealthareanotableandwelldocumentedpolicyconcerninmany countries, including the developing world. This is the case both for more objectivemeasures of socio-economic status or position but also for subjective social status,which hasclosetieswithhealth.Yet,researcherstodatehavenotappliedthestandardanalyticaltoolsofconcentration indices and decomposition analysis to the study of subjective social status andhealth, nor have researchers investigated subjective social inequalities in health in a SouthAfricancontext.

Methods This study employed the cross-sectional 2014 South African Social Attitudes Survey(SASAS). Concentration indices (CI) were used tomeasure subjective social inequalities in theseverity and prevalence of depression. A decomposition analysis was conducted in order todeterminethefactorsthatcontributetosubjectivesocialinequalitiesindepression.DepressionwasmeasuredusingtheCES-D8-itemscale,withanalysesdisaggregatedbysex.

ResultsMorethan35%ofthestudysamplereportedhavingdepression(95%CI33.57–36.95)whilsttheoverallmeanscoreonCES-D8was8.4(95%CI8.30–8.53).Theconcentrationindexfor prevalence and severity of depression were -0.2800 and -0.0673, respectively. Both theprevalence and severity of depression wasmore pronounced in females (36.65 versus 33.77;p=0.0961 and 8.56 versus 8.23; p=0.0021, respectively). The most important contributor tosubjectivesocial inequalities intheprevalenceandseverityofdepression,at48%, issubjectivesocial status itself.Other variables thatmade large significant contributions to the depressionprevalenceanddepression severitywerechildhoodconflict (11%and11%)and race (27%and20%).

ConclusionThisstudyprovidesevidencethatdepressioninSouthAfricaisconcentratedamongthose with a lower subjective social status. We find that the prevalence and severity ofdepressionwashigherinfemaleswhencomparedtomales.PoliciesthataddressinequalitiesinSSS and childhood adversity should be adopted to address depression inequalities in SouthAfrica.

Economic burden and mental health of primary caregivers of perinatally HIV exposed and infected adolescents from Kilifi, Kenya

PatrickV.Katana1,AminaAbubakar1,2,3,4,JulieJemutai1,51 KEMRI/Wellcome Trust Research Programme, Centre for GeographicMedicine Research (Coast), Kilifi,Kenya.2ChildandAdolescentStudies,UtrechtUniversity,Utrecht,Netherlands3DepartmentofPublicHealth,PwaniUniversity,Kilifi,Kenya4DepartmentofPsychiatry,UniversityofOxford,Oxford,UK5HealthEconomicsResearchUnit,KEMRIWellcomeTrustResearchProgramme,Kilifi,Kenya

Background. Eighty percent of perinatally HIV exposed and infected (PHEI) adolescents live insub-SaharanAfrica (SSA), a setting also characterizedbyhugeeconomicdisparities andhigherburdenofmentalhealthdisorders.NavigatingadolescencewhilelivingwithHIVpresentsspecificchallengesnotonlytotheaffectedyouthbutalsototheirprimarycaregiverand/or immediatefamily. Caregiving is crucial to the management of chronic illness such as HIV/AIDS, but theeconomic costs and mental disorders borne by caregivers of PHEI adolescents often gounnoticed. In this study, we establish the economic costs and evaluate the mental health ofcaregiversofPHEIadolescentsfromruralKilifi,Kenya.

Methods:Weusedacostofillnessanalysisapproach.MentalhealthwasassessedusingPatientHealthQuestionnaire(PHQ-9).Cross-sectionaldatawerecollectedfrom121primarycaregivers


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of PHEI adolescents in Kilifi. Economic costs were categorized either as direct costs (costs ofmedicine,consultation,diagnosticprocedures,foodandtravelinseekingcare)andindirectcosts(productivitylossestocaregivers).IndirectcostswereestimatedasvalueofproductivedayslostbyaprimarycaregiverwhilecaringforaPHEIadolescent.WeemployeddescriptivestatisticstoassesstheeconomicburdenandmentalhealthofprimarycaregiversinthecourseofcaringforaPHEIadolescent.

Results:TotalmonthlydirectandindirectcostsperprimarycaregiverwasKsh2773($27.73),onaverage. Key drivers of direct costswere transportation (67%) andmedications (13.7%). Totalmonthly costs represented 28.3% of the reported caregiver monthly earnings. About 10.7 %(PHQ>=10) of primary caregivers reported depressive symptoms. Indirect costs (productivitycosts)wererelativelyhigheroncaregiverswithdepressivesymptoms.

Conclusion:TheevaluationshowsthatHIV/AIDShascausedasignificanteconomicburdenandmental health impact on caregiverswhile caring for PHEI adolescents. Results underscore theneedfordevelopingsocio-economicprogramstoimprovementalhealthofcaregiversandhelpthemreduceeconomicburden.

Parallel Session 5-6 Evaluating PHC performance 2

It’s not enough to tweak old models: Urban PHC calls for new paradigms and approaches

DrReneLoewenson,TrainingandResearchSupportCentre/EQUINET,BoxCY651,Harare,263-4-708835

By2050,urbanpopulationswillincreaseto62%inAfrica,agrowththatUNorganisationsnotetobeoneof themost importantglobalhealth issuesof the21stcentury. In2016-8,wegatheredand analysed diverse forms of evidence and experience on inequalities in urban health, itsdeterminantsandresponsestoitwithineastandsouthernAfrican(ESA)countries.Thisincludedliterature review, analysis of quantitative indicators, content analysis of evidence on practicesandparticipatory reviewbyyouth inLusakaandHarare.The literatureonurbanhealth inESAcountries appears to lag behind the rapid,multifactorial changes taking place in urban areas,focusingonnegativehealthoutcomesrather thantheassets forhealth,pointing toweak linksbetween primary care services and urban public health and limited collaborative interactionacross sectors. Participatory reviewwith urban youth in two cities suggested that ‘health’ hasbecomenarrowlyandmedicallydefinedintheirexperienceandexperience,poorlyreflectingthepsycho-social, economic and environmental determinants they see as associated withimprovements in their health. In other regions globally, the concept of ‘wellbeing’ bettercapturesthisbroaderlens,andisbeingaccompaniedbymeasurementofitsvariousdimensionsasindicatorsofnationalprogress.Ouranalysisofthecrosscountryhealthdatacollectedinthe16 ESA countries foundmore limited assessment of suchmeasures, with a focus on negativehealth outcomes, ignoring themany socially-defined dimensions of vulnerability, variations inrisk environments and assets that are important for urbanhealth. These findings suggest thatmeeting the growing challenges in urban health for our region demands newparadigms, newapproachestourbanPHCandnewindicatorstoinformanalysisandplanning.ItimpliesframingurbanPHCwithinamoreholistic‘wellbeing’paradigm,encompassingphysical,material,psycho-social and ecological dimensions, with space for diverse forms of local knowledge and public


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voice;awayfromanurbanPHCthatissingularlypreoccupiedwithmanagingnegativeoutcomesandthatseespeopleashealth‘problems’,togreateruseofassetbasedapproaches.Thisimpliesamore organised, continuous relationship betweenour urbanprimary care services and theirpopulationsthanthecurrentlyadhoconeofpeoplepresentingtofacilitieswithproblems,withproactivemeasuresforfamilyandpopulationhealth,reachingintocommunitysettings,workingwithandasanentrypointforotherservicesthatsupporthealthandacontributortoprocessesformeaningfulresidentparticipationinurbanplanning.

Strengthening Primary Health Care for the Proper Management of Tuberculosis in Côte d'Ivoire

Marie-CatherineBarouan,TaniaBissouma-Ledjo,Jean-MarieViannyYameogoandMosesZangaTuhoWorldHealthOrganization,OfficeofRepresentationinCôted'Ivoire,AbidjanNationalIndependentConsultant,Abidjan

BetterprogresstowardsUniversalHealthCoverageimperativelyrequirestheimplementationoftargetedinterventions,particularlyatthelevelofprimaryhealthcareaimedatimprovingequityinaccesstoqualityessentialhealthservicesforthepopulation.theyarefound.

AspartofthefightagainsttuberculosisinCôted'Ivoire,thenationalresponsedevelopedbythegovernmentwith its technical and financial partners involved for several decadeshadallowedthe establishment of a network of care for the treatment of tuberculosis. reported cases oftuberculosis. However, the provision of care that can be summarized as 160 tuberculosisdiagnostic and treatment centers (CDT) remains unsatisfactory with a ratio of 1/145000inhabitants for an estimated incidence in 2016 to 91 cases per 100 000 inhabitants and amortalityrateof23/100,000peoplemakingTBoneofthemajorpublichealthconcernsinthecountry.

Inorder tostrengthen thenational responseand increase theaccessibilityofTBcareservices,the government has made a strong commitment to implement WHO's recommendation toimplement an intervention aimed at extension of CDTs to many peripheral centers in thecountry.

Theinterventionmethodologyconsistedin:(i) identifyingnewCDTimplementationsitesbasedontheirrealneeds inordertobringtheservicesclosertothebeneficiariesand(ii)makingthestructuresfunctionaltooffertheservicepackagediagnosisandtreatmenttomeettheneedsofcommunities.Asaresultoftheintervention,62newsiteswerecreatedandthecapacityofthehealthstaffof543primaryhealthfacilitieswasstrengthenedinthedetectionandtreatmentoftuberculosisaccordingtonationalprotocolsandguidelinesofcareinforce.

Thus,thenumberofCDTsincreasedfrom160in2015to238attheendof2017withacoverageratio in CDT increased from 1/145000 to 1/93 000 in 2017, thus allowing a reduction ofdisparitiesexistingincertainhealthregions,particularlyAbidjan.

Nevertheless, the challenge remains the involvementof the community, all civil society actorsforabettercommunityengagementintheuseofhealthservicesandtheachievementofbetterresultsfortheeliminationoftuberculosisinthelongterm..

Keywords: Universal health coverage, Tuberculosis, primary health care, health services,extension,IvoryCoast

Community health workers in Mali, costs of including their services in the PHC-UHC


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SPEAKER:PascalSaint-FirminTHEMATIC TRACK: #4 Community Health Systems – Where Community Needs are Located

CO-AUTHORS:BiramaDiakite,SeydouTraore,BakaryDiarra*,(*FormerSecretaryGeneraloftheMOHwhoassisteduswithdatacollection,liaisingwithgovernmentofficialsanddevelopmentofrecommendations)

Background:Current and future health workforce production worldwide fails to meet therequirements for Universal Health Coverage (UHC). Primary health care (PHC) built aroundCommunityHealthWorkers(CHWs)canserveasthefoundationforUHCandplayacentralrolein achieving the health-related targets of the Sustainable Development Goals (SDG). Village-basedCommunityHealthWorkers(CHWs)inMalihavebeenacost-effectivealternativetoboostaccessto,demandfor,anduseofkeyprimaryhealthservicesbybringingservicesclosertooverthreemillionMalianslivinginruralareas.However,thishighlydonor-dependentprogramisnotsustainableinaneraofstagnatinginternationaldevelopmentassistanceforhealth.Thereisanurgent need to support a transition from external to domestic sources of funding to ensureservice continuity at community level. To support the Government of Mali (GOM) inunderstandingthefundingandworkforcesituation,costsoftheCHWprogramandthreatstothesustainabilityof this frontlinehealthworkforce, theUSAID-fundedHP+conductedexpenditureandresourcemappingexercisesfollowedbycostsanalyses.

Methods: HP+ applied computerized cost modeling and mapping methods to look atexpenditures, funds available, and CHW service package cost. Information collected includedCHW numbers and deployment, expenditures mapped by region and source, fundingcommitmentsby sourceandareaof investment, andprogram inputunit costs. Fundingneedsfromcostprojectionswerecomparedtoactualexpendituresandfundingavailabletoestimategapsinthenextfiveyears.

Results:TheaveragecostofthepackageofserviceprovidedbyCHWsisestimatedat$6.79andwill decrease to $2.52 by 2020 if benefits of increased workforce productivity, technical andallocativeefficiencyfromcompliancetonationalstandardsareleveraged.Thegapanalysisthatin2015,US$8.36millionwasneededfortheCHWprogram,andthisisexpectedtoriseto$14.15millionby2020.Meanwhile,fundingfromdonorsisexpectedtofallfrom$13.01millionin2015to$9.71millionin2020,resultinginacumulativefinancialgapof$18.75millionforunderfundedareasby2020(12.8%ofgovernmenthealthexpendituresper2014NationalHealthAccounts).

Conclusions:Toensureadequatefundingforvillage-levelcommunityhealthservicesweproposeatwo-prongedapproach:

-Increaseddomestic resourcemobilizationand targeted financial supportbyGOMto theCHWprogram

-Improvedcoordinationamongdonorstoavoidduplication

Assessing Health Systems Readiness for Primary Health Care Financing: Lessons Learned from Kaduna and Niger State, Nigeria

RachelNeill(onbehalfofResultsforDevelopmentInstitute(R4D)),co-authors:Dr. Chris Atim, Tamara Chikhradze, Rachel Neill, Ezinne Ezekwem, Chloe Lanzara, Felix Obi,Oludare Bodunrin, Alexander Nzobiwu, Anam Abdulla, Jack Sullivan, University of Nigeria Nsukka: Dr.HyacinthIchoku A readinessassessmentwas conducted inNiger andKaduna states,Nigeria toevaluatehealthsystem status against Universal Health Coverage (UHC) components, as they relate to states’


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readiness to launch PrimaryHealthcare (PHC) centered financing initiatives.7The objectives ofthe study were to: 1) assess the current state of health system; 2) highlight challenges andopportunities for health care financing reform initiatives; 3) present approaches towards thedesignandimplementationofPHCfocusedfinancingreforms;and4)mapstatestakeholderstoassessthefeasibilityandacceptabilityofkeyaspectsofUHCreform.

Theassessmentemployedamixedapproachandreliedonqualitativeandquantitativemethods.Acombinationofprimaryandsecondarydatawasused.Thequantitativecomponentexploredfiscalspaceforhealthandthequalitativeoneexaminedthehealthsystemfromtheperspectiveofitsusersandmainactorsatthefederal,state,localgovernment,andcommunitylevels.

Theanalyticalframeworkwasdevelopedspecificallyforthisstudy,drawingontheWorldHealthOrganization’s Comprehensive Health Systems Assessment Approach (Health Systems 20/20,2012) and theWHO’s Health Financing Policy Objectives (Kutzin, 2008). It captured status ofhealthsystems,accordingtothesixhealthsystemsbuildingblocksandanalyzedthosefindingsagainst a series of criteria linked to financing functions of resourcemobilization, pooling andpurchasing. In addition, Management Sciences for Health’s Social Insurance Assessment Tool(MSH 2002)was adapted to capture the feasibility and acceptability of components of healthfinancing reforms. A political economy and stakeholder analysis were also conducted todetermineperceptionsandstancesonUHCreformandtomaptherolesandresponsibilitiesofallstakeholders.

Findings and preliminary recommendations were validated with state stakeholders in aworkshopsetting,wheretheyidentifiedpriorityinterventionsforachievingstates’UHCgoals.

The study produced findings that highlighted challenges and opportunities on both – demandand supply sides. These included gaps in service availability and readiness, service utilizationtrends,statefundingallocationstothehealthsector,andfragmentationofpooling,purchasing,anddatamanagementarrangements.

The assessments developed evidence-based recommendations to improve the states’ capacityforimplementingUHCreforms.Forexample,forNigerstateitwasrecommendedthattheStatereframe advocacy efforts and utilize a proof-of-concept to demonstrate better returns oninvestment for the health sector, while for Kaduna state it was advised that the Statemergeexistingfinancinginitiativesintothehealthinsuranceschemetoreducepoolingfragmentation.

Implementation process and quality of a primary healthcare system improvement initiative in a decentralized context: A retrospective appraisal using the Quality Implementation Framework

Ejemai Eboreime, Nonhlanhla Nxumalo, John Eyles: Abuja National Primary Healthcare DevelopmentAgency,CentreforHealthPolicy,SchoolofPublicHealth,UniversityoftheWitwatersrand

Background:Effectiveimplementationprocessesareessentialinachievingdesiredoutcomesofhealth initiatives. Whereas many approaches to implementation may seem straightforward,carefuladvancedplanning,multiple stakeholder involvementsandaddressingothercontextualconstraints needed for quality implementation are complex. Consequently, there have beenrecentcallsformoretheory-informedimplementationscienceinhealthsystemsstrengthening.

7The assessment in Kaduna was conducted in collaboration with Health Systems Consult Limited


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Aim: This paper applies the Quality Implementation Framework (QIF) developed by Meyers,Durlak and Wandersman to identify and explain observed implementation gaps in a primaryhealthcaresystemimprovementinterventioninNigeria.

Methods:We conducted a retrospective process appraisal by analysing contents of 39 policydocument and 15 key informant interviews. Using the QIF we assessed challenges in theimplementation processes and quality of an improvementmodel across the tiers of Nigeria’sdecentralizedhealthsystem.

Results: Significant process gaps were identified which may have affected subnationalimplementationquality.Keychallengesobserved include inadequatestakeholderengagementsand poor fidelity to planned implementation processes. Although needs and fit assessments,organizationalcapacitybuildinganddevelopmentofimplementationplansatnationallevelwererelativelywellcarriedout,thesewerenoteffectiveinensuringqualityandsustainabilityofDIVAatthesubnationallevel

Conclusions:Implementinginitiativesbetweenlevelsofgovernanceismorecomplexthanwithina tier. Adequate pre-intervention planning, understanding and engaging the various interestsacrossthegovernancespectrumarekeytoimprovingquality.

The PHC policy in Côte d'Ivoire: An assessment at the Bouaflé Health District

MEMONFOFANA,ALLYYaoLanzali:Abidjan,KorhogoUniversity,MinistryofPlanningandDevelopment

Anevaluative readingof the implementationof thepolicyofPrimaryHealthCare (PHC) in theDistrictofBouaflé,pilotdistrict inCôted'Ivoire,allowstonotethe failureof thepromotionofprimary health as envisagedby theBamako initiative in 1987 and later in 1978by theALMA-ALTAconference.

Indeed,despitethepresenceofaCHR,twoschoolsanduniversityhealthcenters,19ruralhealthcentersand3urbanhealth centers. TheobjectivesofPHC / IB (PHC,Bamako Initiative) in thehealthdistrictofBouaflé,pilot center for the implementationof this initiative isnotachieved;someindicatorsallowustodemonstrateit.Theincidenceofdiarrheaamongchildrenunder5in1999is65%ocomparedto53%nationally;theincidenceofmalariaincreasedbetween1995and2000,atthenationallevelfrom68.9per1000to83.6per1000andintheBouafléDistrictof72.6percentin1996;81.2%in1997and73.1%in1999and68.0in2005.Theuseofhealthfacilitiesremains the lowest in thehealthdistrictofBouaflé from1997to theyear2000. Itwas24,1%and1997, from21.4 in1998, to19.9% in1999and18.3% in2000.Whatarethesocial factorsthat account for this failure? The look at thephenomenon is thus anchored in thehypothesisthatthisfailureisexplainedbythemismatchbetweensupplyanddemandforhealth.

Parallel Session 5-7 Governance and accountability 2

Population empowerment is one of the strategy for strengthening primary health care in Mauritius.

DR.LaurentMUSANGO¹;Mr.PremduthBURHOO²;Dr.FaisalSHAIKH¹;DR.MaryamTIMOL³¹WorldHealthOrganisation,CountryOfficeofMauritius.²MauritiusInstituteofHealth(MIH)


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³MinistryofHealthandQualityofLife(MOHQL)

Introduction: Health promotion is a core component of health intervention programmes andcommunity empowerment is oneof themain approaches topromotehealth.All thedifferentNationalActionPlansbeing implemented to improvehealth andqualityof lifehave strategiesdefined to increase health literacy. In linewith these Action Plans theMinistry of Health andQuality of Life regularly conducts community awareness programmes, health promotionprogrammes and information campaigns on disease prevention. The Ministry of Health andQualityof Lifehasdedicated structuredunits for theplanningand implementationofpolicies,programs, services, and activities to increase levels of health literacy and many activities ofhealthpromotionare complementedbyotherministries andnon-governmentalorganizations.Despite the various strategies implemented for population empowerment, several indicatorsshow that several problems remain and need to be improved. Reasonwhy an assessment onpopulationempowermenttostrengthenprimaryhealthcareinMauritiuswasinitiated.

Methodology: The country assessment starts with a thorough analysis of the situation ofpopulation empowerment over the past 15 years. Challenges or present opportunities forimproving population empowerment were then carried out. A participatory and flexibleapproach was used for this assessment; amultidisciplinary teamwas set up to carry out theassessment.AWorkingGroup(WG)of6memberswasconstitutedtoreviewandtovalidatethereport. The report identified keys opportunities that the countrymay continue to build on aswellaschallengesandpossiblesolutionsforpopulationempowermentasoneofthestrategyforstrengtheningprimaryhealthcareinMauritius.

Results:TheassessmentidentifiedopportunitiesmentionedaboveandchallengesthatneedtobemitigatedforimprovingPHCinthecountries.Thechallengesidentifiedare:(i)thepopulationisnotadequatelyempowered tochangebehaviour towards taking responsibility for their ownhealth; (ii) the population is not engaged actively in decision-making processes both aroundpolicy issues as well as individual treatment options/plans; and the high-risk populations,disadvantagedgroupsincludingtheincreasingelderlypopulationarenotadequatelytargetedformoretailoredhealthpromotionandhealtheducation.

Conclusion and recommendations: The assessment recommended to strengthen communitymobilization and participation to promote health literacy including behaviour change in thepopulation, to fully leverage information technology to support health literacy and patientempowerment, toensureadequateandwell-trainedhuman resources tobetter empower thecommunityandtotargethigh-riskpopulationsanddisadvantagedcommunitiesincludingelderlypersons for more tailored health promotion and health education. All recommendations arebeing implemented by the Ministry of Health and Quality of Life to empower population tocontributetostrengthentheprimaryhealthcareinMauritius.

Strengthening Regulation for Patient Safety: Front line staffs’ perceptions of Kenya’s regulatory reforms

EricTama,MPH,DoctoralFellow,StrathmoreUniversityStrathmoreBusinessSchool,InstituteofHealthcareManagementOleSangaleRdMadarakaEstate,Nairobi,KenyaOther Authors: Francis Wafula (Strathmore University), Catherine Goodman (LSHTM), Irene Khayoni(StrathmoreUniversity),GilbertKokwaro(StrathmoreUniversity),NjeriMwaura(TheWorldBank)

Background: Health systems in low and middle-income countries (LMIC) are increasinglypluralistic, involving a wide mix of public, not-for-profit and for-profit providers. Regulation


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should be a key foundation of the Government’s stewardship role of these heterogeneousfacilities, but performance of this function is generally weak, with serious consequence forpatient safetyandqualityof care. Inaneffort to improve regulationofhealth facilities,Kenyaintroducedasetofinnovativeregulatoryinterventionsinpublicandprivatefacilitiesin3Kenyancounties. These comprised the use of the Joint Health Inspections Checklist (JHIC), whichsynthesises the areas covered by all the regulatory Boards and Councils; increased inspectionfrequency; risk-based inspectionswherewarnings, sanctionsand time to re-inspectiondependon inspection scores; anddisplayof regulatory resultsoutside facilities.Weaimed toexaminetheviewsandperceptionsoffacilityownersontheseregulatoryreforms.

Methods:Thestudywasconducted in3countiesusingqualitativemethods.Weconducted51in-depth interviews with health facility owners/managers to explore their perceptions andexperiencesoftheimplementationoftheregulatoryreforms.Wespecificallysoughttofindouthow the inspections were perceived in terms of fairness and legitimacy. We also sought toidentifyfacilitatingandimpedingfactorsto implementationandwaysinwhichimplementationcouldbe improved. Finally,weexplored thedifferencesbetween thenew inspectionsand theprevious regime of inspections in terms of efficiency and incentives & opportunities forcorruption.DatawasmanagedusingNvivosoftwareandanalysedusingaframeworkapproach.

Results:Theinspectionsweregenerallyseenasfair,legitimate,transparentandsupportive,anddifferent from previous inspections which were characterised as intimidating and punitive.Facilitieshadimplementedsomepatientsafetymeasuresasaresultoftheinspectionsandtheyfeltthequalityofserviceshadimproved.However,smallerfacilitiesfeltthatsomeofthecontentof the inspectionswasonly relevant tobigger facilitiesand that itwas inappropriate toassessthem on these requirements. Most facilities felt that there was need for mechanisms ofsupporting them to address gaps identified during inspections, especially public facilities thathaveverylittlecontrolovertheirownresourcesandprocesses.Thedisplayofinspectionscoresatfacilitieswassupportedbybetterperformingfacilitiesbutopposedbypoorperformers.Whilethe scorecards were generally not thought to be well understood by patients, there wasevidence that their display motivated health workers to improve. The use of an electronicinspectionchecklistwasperceivedtoreduceopportunitiesforbriberybuttherewerestillafewunsuccessfulcasesofbribesolicitationbyinspectors.

Conclusion:Thesenewinspectionshavebeenreceivedpositivelybyhealthfacilitiesandshouldbescaledcountrywide.Thereisneedtohaveamechanisminplacethatsupportshealthfacilitiesto implement inspection recommendations to improvequality andpatient safety. The generalpublic needs to be educated on the scorecards so that they can understand thembetter andmakeinformedchoices.

Potentialconflictsofinterest–NONE

Funding Source for Research – This research is supported by funding from the MRC, ESRC,WellcomeTrustandDFIDthroughtheHealthSystemsResearchInitiative(HSRI)and isthesoleresponsibilityoftheauthors.

Does Governance Impact Undernutrition: An Integrated Approach to Reducing Underweight in Children Under 5 years

G.WoodeR.BirnerFAsante

Objectives: To evaluate the effect of governance on nutrition program outcomes for childrenunder 5 years with reference to the human resource capacity required and expenditure fornutritionprogramsforefficienthealthcaredeliveryinGhana.


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Methods:Amixedmethodapproachwasusedincludingkeyinformants’interviewswithexpertsfromnutritionunitoftheGhanaHealthService,unitednationschildren’sfund(UNICEF)-Ghana,communitymother-to-mother support groupsaswell as anthropometricdata from theGhanaHealthServicemonthlynutritionandchildhealthform,fromnorthernregionofGhana.Afour-year panel data (2014-2017) comprising anthropometric measurements of weight and age ofchildren0-59monthsrecordedduringroutinecommunityandfacility-basedGrowthPromotionactivitiesinthenorthern,centralandGreaterAccraregionspurposivelysampledwastakenwiththeir Z-score means and proportion underweight calculated using excel. Linear Mixed-Effectmodelling inSPSS(Statisticalpackage)wasalsousedtoestimatetheeffectofhumanresourceand expenditure for nutrition program implementations by accounting for the covariates thatpredictthereductioninunderweight

Results:Betweentheyear2014–2017,apartfromGreaterAccraregion,therewasanincreaseinplacementofkeystaff fornutritionprograms inthetwootherregions,complimentedbyanincreased funding for training, supportive supervision, monitoring and for commodities.Nutritioncounsellingwastailoredtotheconsumptionofnutrient-richvaluechainproductssuchaslegumes,andorange-fleshedsweetpotatoforcomplementaryfeedingandformaternaldiet.The results show that, thepercentof children less than5 yearsof age registered inwell-childclinics with global malnutrition (weight-for-age) less than 2 Standard Deviation below thestandardmeandecreasedbybetween 80%inNorthernregionto49%inGreaterAccraregion.from 20% at the beginning of 2014 in northern region to 4% at the end of 2017(95%CI:-1.2021.25) Cohen’s d=3.6, from 11.13% to 4.6% (95% CI: 2.89%-11.98%) in Central regionrepresenting a 59% reduction in underweight Cohen’s d=4.4 while Greater Accra had a 49%reduction inunderweight from7.21% to3.71% (95%CI: 2.81%-7.61%)Cohen’sd=2.8over thesame period. However, human resource capacity and quantity with requisite expenditure fornutrition programs although important, were not significant predictors of underweight inchildrenunder5years.

Conclusion:Our results indicate government failure,externalitiesand rent seekingbehaviour,howevercommunityfactorssuchasnutritionrelatedbehaviorchangethroughthepromotionofnutrition-sensitive agriculture, consumption of nutrient-rich value chain products as well ascommunitysupportgroupsarevitalinreducingmalnutritionandunderweightinchildrenunder5yearsinthetargetedregionsinGhana.Therefore, improvingcommunitygovernancesystemscouldbeassociatedwithimprovementinnutritionalstatusofchildrenunder5yearsinresourcechallengedsettings

Keyword:Governance,FoodandNutritionSecurity;malnutrition,socialsupport

Process of Selection Improves Membership Composition and Representativeness of Horizontal Accountability Structures for Phc Strengthening: Case Study 0f Four Health Facility Committees

ChinyereMbachu,UniversitéduNigériaNsukka

Background:Healthfacilitycommittee(HFC)isarecognizedcommunityaccountabilitystructurethatcontributestostrengtheningprimaryhealthcaresystems.EvidenceshowsthatmembershipcompositionofHFCsaffectsfunctionalityandimplementationofroles.Inlightoftheforegoing,theDepartmentforInternationalDevelopment(DFID),throughthePartnershipforTransformingHealth Systems 2 (PATHS 2) project, implemented ‘voice and accountability’ interventions inselectedcommunitiesinNigeria.Thehealthfacilitycommitteemodelwasidentifiedasthemostviable community accountability structure and an entry point to the interventions. The firstphaseoftheinterventionwasestablishmentorreactivationofHFCsthroughaselectionprocessthatwouldaddressissueswithmembershipcompositionandrepresentativeness.Thisstudywas


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undertakentodeterminewhetherandhowthese interventionsonprocessofselectionofHFCmembersimprovedtheircompositionandrepresentativeness.

Method:Casestudyapproachwasundertaken.UsinginformationfromapreviousassessmentoffunctionalityofFHCsthatwassupportedbyDFID-PATHS2project,fourHFCsofprimaryhealthcentreswere purposively selected from two LGAs in Enugu state. Qualitativemethod of datacollectionwasemployedthroughin-depthinterviews(IDI)ofkeystakeholdersandFocusGroupDiscussions(FGDs)withHFCs.Atotalof9 IDIsand4FGDswereconducted.Datawasanalysedusingthematiccontentapproach.

RESULT: The process of selection involved three stages namely, (1) advocacy to communityleaders to introduce the initiativeand seek theirbuy-in, (2) community fora involvingall adultmemberswithinaPHCcatchmentareatonominateanddeliberateonpotentialrepresentatives,and (3) selection of FHCmembers in accordancewith a guidelinewhich recommends that, (i)communitieswouldnominate theirown representatives, (ii) all catchmentareas accessing thesamehealthfacilitywouldhaveat leastonerepresentative inthecommittee,(iii)at leastone-thirdofcommitteemembershipwouldbewomen,(iv)marginalisedgroupssuchassettlerswillbe represented, (v) healthworkers and relevant occupational groupswill be represented, and(vi) community leaders would only act as patrons in the selection process. Adherence to theguideline for selectionwasmonitored and enforcedby technical experts, government officialsand community-basedorganizations. Theoutcomeof theprocesswas thatHFCS’membershipwasrepresentativeandeffectivelyavertedanelitistcapturethatmayhaveresulted.

Conclusion: Community voice and accountability interventions on process of selection of HFCmembers resulted in gender diverse and representative committees that could potentiallyimprovehealthsystemsresponsivenesstothecommunitiesserved.

• Contact-ChristineOrtiz,HealthPolicyPlus,Palladium,2023526647,[email protected]

• Presenter:Dr.GeraldManthalu(MinistryofHealthMalawi)• Co-authors: Anne Conroy (Ministry of Finance Malawi-funded through USAID/HP+),

HenryMphwanthe(HealthPolicyPlus),ChristineOrtiz,PalladiumGroup• Sub-Theme2:Theeffectivenessofaidinthebuildingofhealthsystems

Increasing fiscal space for health in Malawi: More resource mobilization or increased absorption capacity of existing resources?

ChristineOrtizWashingtonDCThePalladiumGroup-HealthPolicyPlusDr.GeraldManthalu,MinistryofHealthMalawi,HenryMphwantheandAnneConroy

Background: InMalawi,MultilateralandBilateralpartnerscontributeabout75percentoftotalhealthcarefunding.Mostofthisfundingisinformofgrants.Thereis,however,growingconcernover low absorption rates in major grants which has constrained the delivery of key healthinterventions.Thishappensinacontextoflimitedfiscalspaceforhealthandactivehealthsectorresource mobilization efforts by Government. Understanding the potential for increasedresourcemobilizationandefficientutilizationofexistingresourceswillhelpGovernmenttofocusitsefforts.

Objective:TheprimaryobjectivewastoadvocateforimprovingabsorptionratesofgrantsinthehealthsectorinMalawiversusincreasedresourcemobilizationforhealth.

Methodology:Existingreportsanddatawereanalyzedtoassesstheeffectsoffundingsources,grant characteristics, type of grant recipients and fiduciary governance mechanisms onabsorption. The potential domestic resources that can bemobilized from innovative financing


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optionswerealsoanalyzedandcomparedwithefficiencygainsfromimprovedabsorptionsrates.ThegrantsoffocuswereGlobalFund,AfricanDevelopmentBankandHealthServicesJointFund(HSJF).Keyinformantinterviewsfocusingonimplementationprocesseswerealsoconducted.

Findings:Initialresultsshowedthatifallviableearmarkedtaxeswereintroduced,amaximumofUS$11.6millioncouldberaisedperannum.ThisisequivalenttoUS$0.63healthexpenditurepercapita. Thepotentialadditionalrevenueisasmallfractionofthefinancinggapforhealth.Theabsorptionrateunderthe2016-2017GlobalFundGrantforMalawiwas81percentimplyingthat19%(worthaboutUSD54million,USD3percapitahealthexpenditure)wasnotabsorbedwhiletheabsorptionoftheHealthServicesJointFundforthe2017/18financialyearwas30%meaning70%(USD15million,USD0.83percapitahealthexpenditure)wasnotabsorbed.

Conclusions: The potential for raising significant additional revenue for health is limited inMalawi.Improvingtheabsorptionofexistingresources,forexampleGlobalFundgrantsandtheHealthServicesJointFund,mayprovidethebestoptionforincreasingfiscalspaceforhealthinMalawi.

Impact of the regulatory health workforce information system in Zambia

KalongoHamusonde1*,ElizabethJere2,ChinemaChiliboyi3,AstoneChanda4,SuwilanjiMwelwa5JhpiegoZambia,8NgumboRoad,Longacres,Lusaka,ZambiaHealthProfessionalCouncilofZambia,WamulwaRoad,Thornpark,Lusaka,Zambia Introduction: The shortage of health workers has been a growing concern in several Africancountriesworldwide.NotonlyhasHIV/AIDSbeenamajorculpritinthedeficitofhealthworkersbut also the skill imbalances, geographical and sectorial maldistribution and also the lack ofinformationon theactivehealthpractitioners ina country. Inorder to reach the internationalhealthdevelopmenttargets,sub-Saharancountriesi.e.Zambiainclusive,willhavetoscaleupitsworkforcetremendously.Itisforthisreasonthatin2014,EmoryUniversityfundedaprojectinZambiatobuildaregulatoryHumanResourceInformationSystem(rHRIS) inwhichinformationonallhealthpractitionerswasstored.TheobjectiveofthispaperwastoascertaintheimpactofdataintherHRIStostrengthenhumanresourceplanning,policyandmanagement.

Methods: Amixedmethoddesignwasused in this study.Qualitativedatawasobtained fromsemi-structured interviewswith twoseniorofficialsat theregulatorybodies.QuantitativedatawasextractedfromtherHRISdatabase.

Results:Data from the rHRIS showed an increase of over 80% in practitioner registration andover60%inlicenserenewalofhealthprofessionalssincetheinceptionoftherHRISin2015.Duetothepositiveresponseinpractitionerregistration,practitionerswiththerightskillshavebeenplacedintherightfullocationswhichhasinturnimprovedtheuptakeofqualityhealthservices.Additionally, there has also been an increase in the registration and accreditation of healthfacilitiescountrywideresulting toqualityhealthcare. Interviewswithseniorofficialscited theusefulness of the rHRIS data particularly in the tracking of license renewal by both healthpractitionersandhealthfacilitieswhichisoneoftherevenuestreamsfortheregulatorybody.Itwasalsocitedthatdatafromthesystemledtoalicenserenewalamnestywhichallpractionerswhere allowed to renewal their practicing licenses for the year 2017 without being chargedpenaltiesforarreas.Thisapproachincreasedlincenserenewalsbyover50%ascomparedtotheyear2016.

Conclusion:Theattainedadvancements inhealthworkforceplanningandmanagementasperthe resultsof thispapermighthavenotbeenachievedasquicklyhad therenotbeena rHRISwith readily available data on the health workforce for the Zambian government. ThisimprovementshowsthattheZambiangovernmentisdeterminedtostrengthenitshealthsysteminordertoprovidequalityhealthcareservicesforitscitizens.


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OS 13 - Public financial management towards better PHC and health sector outputs: Building and disseminating knowledge for accelerated reforms in Africa

Helene Barroy [email protected]

Countriesworldwidearemakingremarkableprogresstowardsuniversalhealthcoverage(UHC)bysubstantially increasingtheshareofpublic funds in their totalhealthexpenditure.Bydoingso,theyhavedemonstratedtheroleofbroaderpublicfinancialmanagement(PFM)asintegraltothe UHC agenda. A robust and transparent overall PFM system (i.e. budget formulation,execution and accountability) can deliver better sector specific results through enhancedefficiency and equity. Progressing towards UHC with given available resources involvesoptimizing not just how public funds for health are raised, but also how they are allocated,managedandaccountedforthroughthePFMsystem.

WhilemanyAfricancountrieshaveinitiatedoverallPFMreforms,keyweaknessesremaininhowpublic resource allocation for health is planned, implemented and accounted for. EnhanceddialoguebetweenfinanceandhealthauthoritiescanstrengthenbasicPFMfoundationsinmanyAfricancountries,whileacceleratingtheirreformagenda.IdentifyingpriorityactionareastodosorequiresknowledgesharingandreviewingPFMbottlenecksthatjeopardizetherealizationofUHC. As countries embark on health financing reforms, streamlining these efforts with PFMreformswillimproveconsistency,alignmentandmaximizeprogress.

Within this nexus, WHO has initiated a program of work to support African countries at theglobal, regional and country levels across top to frontline tiers of health systems. FocusingonheathstakeholderswhilecapturingbottlenecksinimplementingPFMreforms,thisworkincludesdeveloping country assessments, policy dialogue activities, as well as producing anddisseminating global knowledge and guidance. This organized session will contribute towardssettingtheagendaforfurtherregionalresearchinthisareabysharingrecentcountryevidenceon PFM progress in the health sector, and identifying the policy challenges that remain. Thespecificcountryexperiencessharedarebasedonanalyticalandpolicyresearch(bothongoingorcompleted)conductedbyWHOandlocalpartnersinBurkinaFasoandGhana.

Inaddition,TheWHOreport“Buildingstrongpublicfinancingsystemstowardsuniversalhealthcoverage: keybottlenecksand lessons learnt fromcountry reforms inAfrica” isexpected tobepublicallyreleasedatthe2019Afheaconference.Hardandsoftcopieswillbemadeavailable.

AgendaSessionoutline

Paper 1: Building strong public financial management systems towards universal health coverage: Key bottlenecks and lessons learned from country reforms in Africa

DrHélèneBarroy,WHOHeadquarters


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Background:Placingpublic fundingat thecoreofhealth financinghas transformedPFMintoacentralissueforachievingUHC.InAfrica,thePFMchallengeismoreacutethaninotherregionsworldwide,withbottleneckshinderingUHCprogressacrossall stepsof thebudgetcycle, frompreparation toexecution, reportingandauditing.With theview to strengthenoverall efficientuse and accountability of public resources, African countries have initiated reforms of theirdomesticPFMsystemssincethelate1990s.Inmostcountries,arelativelystandardpackageofinterventions has been introduced, including: multi-year expenditure frameworks, budgetformulation reforms, computerized financial management systems, with parallel efforts tostrengthen the basic budget processes. While policy interventions were not sector-specific,health has often been a pilot sector for reform implementation. In most African countries,evidencehighlightsthebenefitsofthesereforms,withsomeadvances inreliabilityofbudgets,resource management and overall accountability of public funds. However, results areheterogonousacrosscountriesoftheregion,andinmanyinstances,fundamentalPFMobstaclesremainacrosssectors.

Studyobjectives:IntheabsenceofeasilyaccessibleandconsolidatedknowledgeonPFMissuesinhealth,themainaimofthisstudyistoidentify,analyseandsummarizethenature,extentandcausesofPFMissuesaffectingthehealthsectorfortheAfricanRegion,withtheviewtobringamutual understanding of the problem. In addition, the report seeks to distil lessons of theeffectiveness of existing PFM policy responses for the health sector, so as to enable Africancountries tailor the PFM response to the health sector’s needs to better support progresstowardsUHC.

Reportstructure:Toorganisereviewfindingsinastructuredandeasily-understandablemanner,this report follows thebudgetcycleapproachdevelopedbyCashinetal (2017), thatmaps thethreemainstagesofabudgetcycle:budgetformation,budgetexecution,andbudgetreporting,and then links them with health financing goals. Consequently, the first report chapter isdedicated to highlighting key challenges and lessons from policy responses related to budgetformation in the health sector. Chapter II deals with the budget execution phase, looking atchallengesfirstandthenreviewingpolicyresponsesinitiatedincountriesoftheregion.ChapterIII isdedicated tobudgetmonitoringandaccountability issues in thehealth sector.Chapter IVsetsoutcross-cuttingissues,focusingontheprocessofPFMreformneededforhealthandtheroleofhealthministries.ChapterVsummarizeskeyrecommendationsforpolicy-makers.

Paper 2: Transitioning from inputs-based budget to program budgets in the health sector: lessons from Burkina Faso

DrAbdoulayeNitiema,MinistryofPublicHealth,BurkinaFaso

Background:Sincetheendofthe1990s,BurkinaFaso-aFrench-speakingWestAfricancountry-has initiated profound reforms relating to the management of public finances, in line withregulations set by the West African Economic and Monetary Union (WAEMU). One flagshipmeasurewithinthisreformwastheintroductionofaprogrammebudget,markingashiftawayfrom a purely input based budget. Institutionalizing this reform in Burkina Faso took twentyyears,withtheadoptionbyParliamentin2017ofabudgetpresentedusingaprogrammebasedapproach-thefirstintheWAEMUregion.TheMinistryofHealthwasoneofthefirstministriesto engage in and institutionalize this reform, by consolidating a budget around three majorbudget programmes that aligned with the National Health Plan (the Plan National deDéveloppementSanitaire(PNDS)).

Studyobjectives:Thestudy’s specificgoalswere toanalyse thestructureof thehealthbudgetbefore and after the reform; to document the process of transition from a line budget to a


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programme budget, focusing on specific projects such as immunization; to analyse the initialeffectsofthereformfromasectorperspective;andtoidentifyusefulrecommendationsforanychangestothecountry’sreforms.

Report structure: The report begins with a contextual review of the developments in theWAEMU regulatory framework and its transposition into national law with respect to theprogrammebudgetandpublicfinancialmanagementmoregenerally.Areviewisalsoconductedofthedevelopmentsinhealthfinancingandtheirlinkstopublicfinance.Thesecondpartofthestudyreportfocusesonthebudgetreformprocess,analysingthevariousstagesinthetransition,includinginthehealthsector,andthevariousplayers’roles inthereform.Thethirdpartdealsmore specifically with the structure and content of the Ministry of Health’s three budgetaryprogrammesand,attherequestofthepartnerssupportingandinvolvedinthisstudy,containsan analysis of the implications of the reform with respect to the inclusion of specificinterventions – such as immunization, HIV/AIDS, malaria, tuberculosis – in the new budgetformulation.The last sectionof the reportanalyses the initial impactof the reformonbudgetplanning, flexibility in managing expenditure and accountability. The study concludes with asummary of the progress and challenges of the reform and highlights some keyrecommendations on adapting the reform to best address the needs of the sector in BurkinaFaso.

Paper 3: Practical realities of implementing program budgeting across the Ghanaian health sector

Mr.DanielOsei,WHOConsultant,Ghana

Background:Ghanahasbeengradually implementingProgrammeBasedBudgeting (PBB)since2010 as away to “deliver results in amore efficient, effective and transparentmanner.”8 Thenewapproachwasadoptedtoorientthebudgetingprocesstowardsperformanceandflexibility.However,practicalimplementationrealitieswhentransforminginput-basedbudgetsforspecifichealth programmes into broader-based budgetary programmes present specific constraints,especiallyasGhana’shealthsectorhasrecentlyfacedincreasingfiscalpressuresandchallengesresulting from donor transition dynamics. The majority of goods and services funding ischanneledthroughtheNationalHealthInsuranceScheme,whichhasitsownproblemswithonly71.4%ofbudgetedfundsreceivedin2016.

Studyobjectives:Thisstudyhastwoobjectives.First,todocumentthetransitiontoPBBwithintheGhanaianhealthsector. This isofparticular importancegiventhe increasingmovementoflow- andmiddle-income countries towards PBB. Second, the analysis will serve as a basis tohighlight ways Ghana is working to reduce duplicative activities or inputs across healthprogrammes,aswellaskeychallengestodoingso,aspartofthePBBtransitionprocess.

Reportstructure:Thestudyfirstdescribesthetransitionfromactivity-basedtoPBB,andexplainsthe structure and content of budget programmes within the health sector and relatedperformance measuring metrics. In the second chapter, the effects of the PBB reforms areanalysedinrelationtostatedobjectivesasthebasistohighlightkeylessonsandchallenges,aswellasrelatedrecommendationsforthewayforwardinthehealthsectorinGhana.

8 Ministry of Finance and Economic Planning, Government of Ghana, 2010 budget guidelines.


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OS 14 – An Activist Agenda for Health Policy and Systems (HPS) Research and Practise in Africa

• Sessionformat:ParticipatoryWorldCafe• Sessionchair:SalmaAbdalla• Sessionorganiser:LeanneBrady• Session discussants: Okiki-olu Badejo, Kefilath Bello, Leanne Brady, Asha George, Lucy

Gilson,KennethMunge,ShehnazMunshi. Inaddition,wewill seek to inviteanactivistandhumanrightslawyerbasedinAccra.

Overviewofsession

The 5th Global Symposium on Health Systems Research started an important conversationrecognisingthat‘ourdemocraciesareunderthreat,oursocietiesmorepolarized,ourecosystemundermined, conflict and diseases such as Ebola continuewithout due political attention, andinequalities,includingthoserelatedtogenderandintersectionalityincrease.Inthefaceofsuchmassivechallenges–socialsolidarity,breakingdownsiloes,smartuseofscarceresources,andinnovationareimperative.’1

Othercentral ideasraisedattheconferenceweretheimportanceofpolitics inhealthsystems,interrogatingpower structures in global health, andwhat a decoloniality lens canoffer to thefieldofHealthPolicyandSystems(HPS)ResearchandPractice.Thesymposiumalsohighlightedthat in this field ‘we have an activist agenda, seeking to promote equity and speak truth topower’ 1 and that indeed, ‘academia is apractical place, that the ivory tower shouldhavenowalls,andthatweshouldbeopento,andinfluencedbytheworldaroundus’2

PurposeRecognisingthatthisfieldisan‘importantplaceforsocialaction’2theEmergingVoices(EV) 2018 Africa cohort would like to host an organised session that creates a platform tocontinue the conversation, take some of these important ideas further, and specificallyinterrogatewhattheymeanforAfrica.

The organised session would also create a platform to have an intergenerational discussion,allowingforlearningfromthosewhoarealreadyestablishedinthefield,andcreateaspacefornewideasfromthosewhohavejoinedthefieldmorerecently.Itwouldspecificallyseektobeagenerativespacethatharvests ideas fromallparticipants in theroomasweco-createasetofideasrelevanttoHPSresearchandpractise inAfrica. These ideaswillbepulledtogetherafterthesessionbytheorganisers,andwillbesharedwithallthoseinattendancetoguideourworkmovingforward.Wewillalsoseektopublishthisasaneditorialtouseasatouchstonetoguidetheworkwedointhefuture.

Technicalcontent(pleaseseesessionoutlineformoredetail)

• TheLiverpoolstatement:fromideastoAction—whatdoesanActivistagendalooklike?• PowerinHPSR• TakingstockofHPSRinAfrica—whatworkhasalreadybeendone,andaretheresearch

prioritiesinAfricamovingforward?

WhiletheEmergingVoices2018Africawouldhostthisspace,wewillspecifically invite leadersandthinkers in the field toshare ideas (seesessionprocessbelow)andwillalsoseek to inviteactivistsworkinginrelevantareastocontribute.Thetargetaudiencewouldbeallmembersofthe HPS research and practice community at AfHEA, and would also specifically be anopportunityfortheHealthSystemsGlobalAfricaregiontore-connectbeforeHSR2020asweco-createideastotakeforward.


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Summaryofplannedsessionprocess

Introduction

• ConceptualstartingpointsofHPSresearchandpractice• Researchasaformofactivism• Objectiveofthesessionistothinktogether,co-produceideasanddiscusspossiblesteps

forward.• Thisorganisedsessionispartofaconversationfocusingonhowourworkcancentre

equity,addresspowerhierarchiesandworktowardsshiftingtheagendaandbuildingsouthernscholarship.

WorldCafé(3x20mins) 70minutes

TABLETOPICS

KEY IDEAS/SUMMARY (discussantwillgivea5minuteinputatthebeginningofeachtablediscussion)KEYQUESTIONSFORPARTICIPANTS DISCUSSANTS

1. TheLiverpoolstatement:fromideastoActionKefilathBello,AshaGeorgeActivist/Humanrightslawyer

AsummaryoftheLiverpoolstatementswillbeoutlined,withafocusonresearchasactivism,andthepoliticalnatureofHPSresearchandpractise.a. WhatpointsaremostrelevantintheAfricancontext?Whatdoesanactivistagendathat

addressesequitylooklike?b. Howdowetaketheseideasforward?Whatarethenextsteps?

2.PowerinHPSresearchandpractice

Breakingdown the “i-sms” (colonialism, racism, sexism, classism,heteronormativism)andhowtheyplayoutinthefieldofHPSRwithbriefoverviewofintersectionalityasalens.

Unpack some of the mechanisms that maintain unequal power relationships (such asknowledge hierarchies, language, aid, health security, eurocentrism) in HPS research andpractice.

a. Inyoursetting,howdoespowerplayoutinhealthpolicysystemsresearchandpractice?Pleasegiveexamples.

b. Howdoweguardagainstperpetuatingpowerhierarchiesinourresearch?(forexample,howdowedomeaningful engaged scholarship, and allow for public participation and“passingthemic”inHPSresearchandpractice?

KennethMunge,ShehnazMunshi,LeanneBrady

3.TakingstockofHPSresearchandpractiseinAfrica

Abriefoverviewoftheworkthathasbeendoneincludinghighlightingexistinggaps.

Forexample: very littleexploratorywork, andvery littlework that looks at thepoliticsofchangehasbeendoneinHPSresearch.

a. What are the essential steps towards shifting the research agenda despite existingfundingpatterns?HowdowecentreAfricanprioritiesandco-produceresearch?

b. WhataretheresearchprioritiesforAfricamovingforward?

Okiki-oluBadejo,LucyGilson


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Plenaryclosing 10mins

Feedbackfrom3tablesandfinalinputsfromparticipants

Outlinenextsteps

References

1.LiverpoolstatementfromHSR2018.

2.HSGLifetimeachieversawardacceptancespeech.LucyGilson.Oct2018

OS 15 – Implementing Bold Reforms towards Financing UHC in a Decentralized Economy: Political Economy, Innovations, and Progress in Nigeria

Background: Nigeria remains the most populous country in Africa with over 200 millionpopulationwithover60%livinginruralareas.Priortocurrentreforms,Nigeriawasnotontracktowards Universal Health Coverage (UHC). The sub-optimal performance of Nigeria's healthsystem can be attributed to the poor financing of the required investments for delivery andmanagementofhealthservices.TheTotalHealthExpenditure (THE)asapercentageofGDP in2016is3.8,whilepercapitahealthexpenditureis$77.

With General Government Health Expenditure (GGHE) as a percentage of the GeneralGovernmentExpenditure(GGE)at5.9%(Federal),4.2%(States),and3.8%(LGAs),NigeriaisstillfarfromAbujaDeclarationof15%spendingonhealth.Sincehealthoutcomesareunfortunatelyintangible,itbecomesmoredifficulttomakeacaseforadditionalfundingtoachieveUHCfromPolicyMakers who apparently would wish to spendmore on areas that will give themmorepoliticalcurrency.ThishasplacedthemostburdenofhealthcareinNigeriaonhouseholdswhoaccordingtheNHA2016spend71.5%outoftheTotalHealthExpenditure(THE).

To demonstrate her strong commitment in fast-tracking progress towards UHC therefore, theFederal Government of Nigeria held the Presidential Summit on UHC in March 2014, whichprescribedactionsthatshouldbetakenforthecountrytoachieveUHC.Laterthesameyear,theNational Health Act (NHAct) was enacted and in 2016, the new National Health Policy wasdevelopedtoprovideclearpolicydirectionsforhealthinNigeria.

A critical part of the reforms was the development and adoption of the National HealthFinancingPolicyandStrategyin2017whichnowprovidesformechanismsthatareequitableandreflectcommitmentsto increasetheproportionofNigerians inthebottom2quintilesthatcanaccess affordable healthcare without any financial barriers. It also details strategies fordecentralizinghealthinsurancewhichhithertocoveredonly4.3%ofthepopulationonapackageof health services and the expansion of the Basic Healthcare Provision Fund (BHCPF) of theNHAct2014whichhasbeenrolledoutinthecountry.

Over the last 5 years,modest gains have beenmade in implementationof current reforms inNigeria. This sessionwill showcase the political economy of implementing these reforms in adecentralized country with 37 federating units, innovations adopted to navigate throughexpected challenges, and current progress made in advancing towards the goals includingimprovingdomesticresourcemobilizationatFederalandsub-nationallevels.


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SessionPlan:

1. 60minutesofshortpresentationsby6Panelists.Topics:

i. ProvidingdecentralizedriskprotectionmechanismforhealthinNigeria:DesigntypologiesandstatusofimplementationofStateHealthInsuranceSchemes–10Mins

ii. WhereareweinearmarkingtowardsImprovingDomesticResourceMobilizationinaDecentralizedState?ThePoliticalEconomyoftheNigeriaBasicHealthcareProvisionFund(BHCPF)–10Mins

iii. PotentialforgainsindomesticresourcemobilizationthroughStateHealthInsuranceSchemes:HowwidecanweexpandtheFiscalSpaceforHealthinNigeria?–10Mins

iv. InnovationsinrevenuecollectionamonginformalsectorforSocialHealthInsurance:LeveragingAdoptiontoensureexpansionofcoverageintheAnambraStateHealthInsuranceScheme–10Mins

v. 5yearsofperformancebasedfinancingexperienceinPrimaryHealthcare:WhatprogresshasNigeriamadeinStrategicPurchasingtowardsUHC?–10Mins

vi. HarnessingandAligningLegislativeFunctionstowardsUHCinNigeria:SharingtheSuccessandimpactoftheLegislativeNetworkforUHC–10Mins

2. 10-MinutePanelDiscussionModeratedbytheChair3. 20-MinuteAudienceParticipationsession4. 5-MinuteWrap-upSession

OS 16 – Translating Evidence to Action: Participatory Approaches for Strengthening Maternal Health Interventions

Implementation process and quality of a primary healthcare system improvement initiative in a decentralized context: A retrospective appraisal using the Quality Implementation Framework

EjemaiEboreime,WestAfricanNetworkofEmergingLeadersinHealthPolicyandSystems(WANEL)

Participatory Action Research (PAR) is an approach to research that seeks to collaborativelyunderstandand change real-world situations, thus it emphasizesparticipationandaction. PARenablesaction througha reflectivecyclewherebyparticipantscollectandanalyzedata in real-worldcontextsanddetermineactionstobetaken.Further,itblursthelinebetweenresearchersand research subjects by empowering participants to become partner researchers as againstbeingmereobjectsofresearch(respondents).PARrequireshealthresearcherstoworkinclosepartnershipwithimplementersandbeneficiariesofhealthinitiatives(e.g.civilsocietyandhealthpolicy makers and practitioners). Thus, these actors learn how to harmonize dissimilar andsometimes competing interests, and collaborate effectively towards improving health systemperformance.

PARhasbeenusedinseveralinterventionsinhealthcaresuchastostrengthenhealthmanager’scapacity, to improvenutritionalpracticesofpregnantwomentowardsreducingoccurrencesof


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LowBirthWeightneonates,toaddresspovertyandsocialinclusioninthelivesofindividualswithmental health challenges, among others. This organized session aims draw lessons from theapplicationofPARinstrengtheninghealthsystemsintheWestAfricanSub-region.

Thesessionwillconsistof3oralpresentations(10minuteseach),onepanelsessioninvolvingthe3presenters.Thereafteranopen“fish-bowl”sessionwillbeconductedtoelicitdiscussionsfromtheaudience.

Oralpresentationsinclude:

1. Adolescent mothers want easy access to antenatal care services in the HohoeMunicipalityofGhana:FindingsfromaParticipatoryActionResearch

2. AParticipatoryActionResearchforhealthsystembottleneckanalysesinaPreventionofMaternaltoChildTransmissionofHIVprogrammeinNigeria

3. Themidwives service scheme: a qualitative comparison of contextual determinants oftheperformanceoftwostatesincentralNigeria

Adolescent mothers want easy access to antenatal care services in the Hohoe Municipality of Ghana: Findings from a Participatory Action Research

SitsofeGbogbo1,2,Martin Amogre Ayanore1,YeeteyEnuameh3,CorneliaSchweppe21SchoolofPublicHealth,UniversityofHealthandAlliedSciences,Ho,Ghana2InstituteofEducation,JohannesGutenbergUniversityofMainz,Germany3SchoolofPublicHealth,KwameNkrumahUniversityofScienceandTechnology,Kumasi,Ghana

Background: Adolescent pregnancy-related complications are the leading cause of mortalityamong females 15 to 19-years of age. Adolescentmothers are at a greater risk of, puerperalendometritis, eclampsia and systemic infections as compared to olderwomen. Antenatal care(ANC) offers opportunities to diagnose and treat such complications, improving pregnancyoutcomesforbothmothersandbabies.

ToachievetheUnitedNationsSustainableDevelopmentAgendaby2030,alotmoreneedstobedone in reducing pregnancy in adolescence and maternal deaths. Deaths during childbirth indeveloping countries are 14 times higher than their developed counterparts and progress atteenagepregnancyeradicationisslow.

Methods:Participatoryactionresearch(PAR)isaresearchapproach,thatsystematicallycollectsempirical data and analyzes it for the purpose of taking action to effect change. Using thisapproach, we explored adolescentmothers’ knowledge, preferences and components of ANCthatrequiredimprovementtoenhancesustainablematernalandchildhealthservices.

The studywas carriedout in theHohoeMunicipality inpartnershipwith theHohoeMunicipalHospital. Facilitators from 4 communities supported participants recruitment and datacollection. Six focused group discussions were held with adolescent mothers, 20 in-depthinterviewswithpregnantadolescentsand6midwiveswerealsointerviewed.Recordeddatawastranscribed, coded, analyzed thematically, interpreted and consequently mapped throughparticipantandfacilitatorevaluationanddiscussion.

Results: Findings revealed that adolescent mothers experience financial barriers that limitedtheir access to antenatal care. Health care provider’s unfriendly attitude and poor resourced


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healthfacilitiesnon-equippedhealthfacilitiesaresomeofthebarriersnotedforaccessinghealthcareservicesamongadolescentmothers.

Conclusions: Broad stakeholder consultation and engagements in designing community basedantenatalcareservicescanhelp improveaccessand limitbarrierstoadolescentantenatalcareservices.Improvinghealthcareprofessionals’training,accesstomedication,laboratoryservices,and enhanced provider-mother focused interaction are vital for improving adolescentmotherhoodhealthoutcomes.Healthfacilitystaffneedtoprioritizeadolescentmothersunmetantenatalcareneeds inordertoensurecontinual improvementsatthecommunityandfacilitylevel.

A Participatory Action Research for health system bottleneck analyses in a Prevention of Maternal to Child Transmission of HIV programme in Nigeria

EjemaiEboreime1,2*,LawalAbubakar3,UsmanGarba3,NonhlanhlaNxumalo1,JohnEyles11CentreforHealthPolicy,SchoolofPublicHealth,UniversityoftheWitwatersrand,Johannesburg,SouthAfrica2DepartmentofPlanning,ResearchandStatistics;NationalPrimaryHealthCareAgency,Abuja,Nigeria3KadunaStatePrimaryHealthCareAgency,Kaduna,Nigeria

Background:ParticipatoryActionResearch(PAR)isanapproachtoresearchthatenablesactionthrougha reflective cyclewherebyparticipants collectandanalysedata in realworld contextsanddetermineactionstobetaken.Itblursthelinebetweenresearchersandresearchsubjectsbyempoweringprogrammeimplementersbecomepartnerresearchersasagainstbeingobjectsof research (respondents). This paper describes the use of PAR in identifying health systembottlenecks in PMTCT programme in two Nigerian Local Government Areas (LGAs) in 2016.Nigeriaaccountsforabout30%MTCTglobally.

Methods:UsingPAR,wesupportedprogrammemanagers inbothLGAs toconductbottleneckanalysis(BNA)onPMTCTinterventionsusingamodifiedTanahashimodel.Themodelmeasuressixdeterminantsof“effectivecoverage”of“tracer”interventions:Availabilityofessentialhealthcommodities and human resources; accessibility, acceptability, continuous utilization, andimpact/qualityofinterventionsdelivered.Bottlenecksareidentifiedasgapstooptimalcoverageofeachdeterminant.Tracerinterventionsinclude:HIVTestingandCounselling,ARVsforPMTCT,andInfantHIVTesting.

Programmemanagersweresupported to identifyconstraintsusing routinedataanalysedonaMS-ExcelbasedBNAtool.Techniqueslikebrainstorming,“5Whys”,affinityanddriverdiagrams,wereusedtoperformrootcauseanalysis.

Results:Wefoundthateffectivecoverageacrossalltracerinterventionswasverypoor.Thiswaslargelyduetopoordemandforservicesaswellaspoorgeographicaldistributionofinterventionfacilities. Generally, health facilities providing PMTCT services had relatively good supply ofcommoditiesand trainedhumanresources todeliver services.On thedemandside, therewasmoreacceptabilityandcontinuityofT&CservicesbywomenattendingANCwhencomparedtoother interventions. Despite availability of commodities and human resources, 39% and 100%HIV positive pregnantwomenwere not receiving ARVs in both LGAs respectively. Contrary topolicyandprogrammeguidelines,78-100%ofHIV-exposedchildrendidnothavebloodsamplestakenforPCRtestswithintwomonthsofbirth.Further,82-100%ofHIV-exposedchildrenwhosebloodsamplesweretakenforPCRtestwithintwomonthswerepositive,indicatinghighverticaltransmissionrates.Actionplansweredevelopedbythemanagerstoaddressandfollow-uponthesebottlenecks.Detailedfindingsarepresentedtablesandfigures.


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Conclusions:OurstudydemonstratesthatBNAusingaPARapproach iseffective in identifyinghealthsystemsconstraints.Thus,itmaybeveryhelpfulinaidinglocalhealthmanagersaddressprogrammeconstraintsquickly,withintheconfinesofavailableresources.

The midwives service scheme: a qualitative comparison of contextual determinants of the performance of two states in central Nigeria Background

Background:ThefederalgovernmentofNigeriastartedtheMidwivesServiceSchemein2009toaddressthescarcityofskilledhealthworkersinruralcommunitiesbytemporarilyredistributingmidwivesfromurbantoruralcommunities.Theschemewasdesignedasacollaborationamongfederal, state and local governments. Six years on, this study examines the contextual factorsthat account for the differences in performance of the scheme in Benue and Kogi, twocontiguousstatesincentralNigeria.

Methods: We obtained qualitative data through 14 in-depth interviews and 2 focus groupdiscussions: 14 government officials at the federal, state and local government levels wereinterviewedtoexploretheirperceptionsonthedesign,implementationandsustainabilityoftheMidwives Service Scheme. In addition, mothers in rural communities participated in 2 focusgroupdiscussions(oneineachstate)toelicittheirviewsonMidwivesServiceSchemeservices.Thequalitativedatawereanalysedforthemes.

Results:Theinabilityofthefederalgovernmenttosubstantiallyinfluencethehealthcareagendaofsub-nationalgovernmentswasasignificantimpedimenttotheachievementoftheobjectivesoftheMidwivesServiceScheme.Participantsidentifieddifferencesingovernmentprioritisationof primary health care between Benue and Kogi as relevant to maternal and child healthoutcomes in those states: Kogiwas farmore supportive of theMidwives Service Scheme andprimary health care more broadly. High user fees in Benue were a significant barrier to theuptakeofavailablematernalandchildhealthservices.

Conclusion:Differentiallevelsofpoliticalsupportandprioritisation,alongsidefinancialbarriers,contribute substantially to the uptake ofmaternal and child health services. For collaborativehealthsectorstrategiestogainsufficienttraction,wherefederatingunitsdeterminetheirhealthcare priorities, they must be accompanied by strong and enforceable commitment by sub-nationalgovernments.

OS 17 – The effect of human resources management on performance in hospitals in Sub-Saharan Arica *PhiliposGile,**ProfessorJorisvandeklundert,*MartinaBuljac*HigherEducationInstitutionsPartnership;andErasmusUniversityRotterdam** PrinceMohammadBin Salman College for Business& Entrepreneurship KingAbdullah Economic CityKingdomofSaudiArabia

Healthcaresystems,particularlyhospitals in low incomecountries (LICs)mainly inSub-SaharanAfrica (SSA) face major health work force labor issue challenges while having to deal withextraordinary high burdens of disease. The effectiveness of Human Resource Management(HRM) is therefore of particular interest for these SSA hospitals. While, in general the


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relationship between HRM and hospital performance is extensively investigated, most of theunderlyingempiricalevidence is fromwesterncountries,andmayhave limitedvalidity inSSA.EvidenceonthisrelationshipforSSAhospitalsisscarceandscattered.WepresentasystematicreviewofempiricalstudiesinvestigatingtherelationshipbetweenHRMandperformanceinSSAhospitals. Following the PRISMA protocol and searching in seven data bases (i.e. Embase,Medline,Webof science, Cochrane, PubMed, Cinahl,Google scholar) yielded2252hits, and atotalof111includedstudieswhichrepresent19outof45SSAcountries.

FromanHRperspective,most studies researchedHRMbundles that combinedpractices fromthe practices domains motivation enhancing, skills enhancing, and empowerment enhancing.Motivation-enhancingpracticesweremost frequently researched, followedby skills enhancingpracticesandempowerment-enhancingpractices.FewstudiesfocusedonsingleHRMpractices(insteadofbundles).Trainingandeducationwerethemostresearchedsinglepractices,followedbytaskshifting.

From a performance perspective, our review reveals that employee(nurses, physicians,midwives) outcomes and organizational outcomes are frequently researched, whereas teamoutcomesandpatientoutcomesaresignificantlylessresearched.

Most studies report HR interventions to have positively impacted performance in oneway oranother.As researchershave studiedawidevarietyof (bundled) interventionsandoutcomes,our analysis doesn’t allow to present a structured set of effective one-to-one relationshipsbetween specific HR interventions and performance measures. Instead, we find that specificoutcomeimprovementscanbeaccomplishedbydifferentHRinterventions,andconverselythatsimilarHRinterventionsarereportedtoaffectdifferentoutcomemeasures.

In viewof the high burdenof disease, our review identified remarkable little evidenceon therelationshipbetweenHRandpatientoutcomes.Moreover,thepresentedevidenceoftenfailstoprovidecontextualcharacteristicswhichare likely to inducevariety in theperformanceeffectsHRinterventions.Coordinatedresearcheffortstoadvancetheevidencebasearecalledfor.

Keywords:HRM,SSA,employeeoutcome,teamperformance,patientoutcome,hospital,healthworkforce,healthcaresystemlow-incomecountries,systematicreview

OS 18 – Promoting access to quality and responsive mental health care and services in Ghana Dr.GinaTeddy,CentreforHealthSystemsandPolicyResearch,GhanaInstituteofManagementandPublicAdministration.JamesDuah,ChristianHealthAssociationofGhanaWendyAbbey,HumanRightsAdvocacyCenterFrancisAcquah,MentalHealthandWell-beingFoundationDr.CynthiaSotie,GhanaHealthService,MentalHealthUnit MentalillnessisconsideredanepidemicthroughoutAfricaduetosystematicfinancial,structuralandpolicy constraints. Historically,mental illnesshasbeenneglected inAfricadue to limited,allocated resources, lack of infrastructures, inaccessibility to health services, profoundstigmatisation,poorqualityofcareandsuperstitiousbeliefsaroundthecauseofmentalillness.In Ghana, access to mental health services continues to be challenged despite recentimprovement in policy and legal frameworks. Mental health disorders affect over 2.8millionpeopleinGhana,butonly2%ofthemhaveaccesstobasicmentalhealthservices.Meanwhile,thecountryhasonlythreespecialistpsychiatrichospitals,16psychiatristsand1,558psychiatric


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nurses in the country. Despite recent efforts to integrate mental health and general healthservices,systematicconstraintshaveledtotreatment,qualityandsupportgapsinbothmentalandgeneralhealthservices.

This organized session aims to create aplatform fordeliberation and collaboration formentalhealth development in Ghana by bringing together key actors to deliberate on their role,functions and capacities towards improving and sustaining mental healthcare and services inGhana. Engaging these session participants will demonstrate how collaboration can enableorganisationstoidentifyconcreteproposalsandstrategiesforimprovedmentalhealthservicesaccessibletoallinGhana.

Themainobjectiveofthesessionistopresentdifferentorganizationalpotentialcontributionstoimproving access to mental health services, engage the organizations in in a usefuldebate/discussion (with other session participants) to identify possible and practical strategicresponses to challenges by governments, NGOs and others actors in the mental health fieldtowardsattaininguniversalhealthcoverageandimprovedprimarymentalhealthservices.

Several interventionsarebeingundertaken toaddress someof the challengesassociatedwithmentalhealthcareandserviceprovisioninGhana.

• The Christian Health Association of Ghana (CHAG) in collaboration with UKAIDintroducedseveralinterventionstoimproveaccesstomentalhealthservices.

• The Human Rights Advocacy Centre (HRAC) and the Mental Health and Well-beingFoundation(MHWF)areprovidingevidencegenerationandadvocacytowardimprovingqualitymentalhealthserviceswithinboththeformalandinformalsector.

• TheGhanaHealthServiceisastrategicpartnertowardspromotingtheintegratedmentalhealthservicesacrossthecountry,yetitisfacedwithseverechallengescreatinggapsintheirpracticesandpolicymandates.

• The Centre for Health Systems and Policy Research is advocating to promote andimproveaccesstomentalhealthcareandserviceswithsupportfromformalinstitutionssuchasworkplacesandschools.Thesesocialinstitutionshavemoralmandatestowardssupportingthewellnessandmentalhealthoftheiremployeesandstudentsrespectively.

Eachoftheseinstitutionsareaddressingfactorsaffectingaccesstomentalhealthcareandhowtoimproveindividualandcommunityparticipationinhealthcareandservices.

The institutionsareaddressing issuesrangingfromallocationofresources,efficiency inserviceprovision,engagingneglectedpopulationsandusingcommunitystructuresasinnovativewaysofpromotingaccesstomentalhealthcare.

This organised session provides two different kinds of ‘main findings’; (a) the individualpresentationsdemonstratetheoutstandingorganizationalcapabilitiesthatarealreadyavailableinGhanathatcanworkcollaborativelytoachieveimprovedaccesstomentalhealthservices;(b)the panelists’ discussion and concurrent engagement with session participants will generateoptions for ongoing collaboration after the session – options to present to government andothers,andtoencourageongoingcollaboration.

This session is organised by the Centre for Health Systems and Policy Research, to create aplatform to promote access to quality mental health services across institutions in Ghanathrough collaboration among policy makers, advocates, researchers and implementers ofpolicies, inordertorespondto institutionalchallengesassociatedwithaccesstomentalhealthservices.


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Abstract #1

Improving the Lives of Persons Suffering from Mental Illnesses in Ghana: An Impact Assessment of the Christian Health Association of Ghana’s (CHAG) Integrated Mental Health Services

Dr.JamesDuah,ChristianHealthAssociationofGhana Introduction and Aim: Like most developing countries, the mental health needs of Ghana ishighlyunmetwithlimitedresources,poorlyallocatedhealthexpenditureandmultiplebarrierstohealthservices.CHAGincollaborationwithUKAIDhaveintroducedseveral interventionsundertheHealthSectorSupportProgrammeforGovernmentofGhana(HSSP)toreducethesegapsinmental health care access and promotion. This impact assessment evaluates the project’soutcome in terms of reducing stigma associated with mental health; re-integrating personstreated from mental illness back into the community; and increasing access through theintegrationofmentalhealthservicestoprimaryhealthcare.

Methods:Thisevaluationstudyinvestigatedninefacilitiesinthreeregions:Ashanti,BrongAhafoand Northern Regions. A mixed methodological approach purposively combined primary andsecondary. Surveys, interviews, documentary analysis and focus group discussions (FGDs)enabledanin-depthqualitativeandquantitativedatatoinformtheevaluation.Allthedatawasappropriatelyanalysed.

Findings: The study revealed that despite 90% of respondents being aware ofmental health,stigmatization towards persons with mental disorders (PMD) is still high (70%), due to theperceptiontowards it.Athirdofrespondents(35%)thoughtsthatPMDaretreatedpoorlyand45%perceivedtheirrelationshipwiththecommunityaspoor.However,integratedserviceshaveenabledanunderstandingofmentaldisorders throughsensitizationbyhealthworkers.73%oftherespondentsunderstoodmentalhealthassicknessof thebraincomparedto16%and11%whothoughtofitascursesandspiritualattacks,andresultingfromdrugsuserespectively.Therehavebeendramaticimprovementinaccesstomentalhealthservicesbyover96%sincementalhealthwas integrated.Patientsareable toaccesshealthcareat their localor regional facilitieswhile30% reportedofbeing supportedby communityhealthworkers in their communitiesascompared to when they depended only on specialized psychiatric services outside of theircommunities.Accesstoinformation,medication,transportation,alternativemedicineswerestillamajorconcern.Survivorsofmentalnotedthatcommunityintegrationisstillverylowandtheirmajorconcernrelatestofundingforcare,qualityandresponsivenessofmentalhealthcare.

DiscussionandConclusion:Thestudyshowedhowrelevantintegratedservicesmustbecoupledwith responsiveness, availability of resources and continued sensitization of communitymembersaboutmentalhealth.WeconcludedthegovernmentcanlearnfromtheexperienceonimplementingtheintegratedmentalhealthservicesfromtheCHAGexperiencetoavertsomeofthe listed challenges especially improving quality of mental services and reduce the levels ofstigmatization.

Abstract #2

Promoting Quality Access to Mental Health Care Services using community structures such as Traditional Mental Health Centers in Ghana

WendyAbbey&GeorgeOwoo,HumanRightsAdvocacyCenter

Introduction&Aim:Ghanalikemanydevelopingcountries isrecognizedformakingsignificantstridesattheendoftheMillenniumDevelopmentGoals.Yet,verylittlewasachievedinmental


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health, improved access and quality of care leading to inequity, inaccessibility and socialexclusionforthoseindesperateneedofmentalhealthservices. It isestimatedthat2.8millionpeoplelivewithmentaldisabilityinGhana,yetlessthan2%accessmentalhealthservices.Thesystematic challenges in providing mental health services cuts across the country leading totreatment gap of about 98%. The Traditional Mental Health Centres (TMHC) are communitysystems that complements formal mental health services. Yet, there is a general lack ofawareness and understanding of the practices, services, management, regulations, rights andresponsibilitiesofTMHCs inGhana.This studyexplores the roleofTMHCs inprovidingmentalhealthservices,qualityofcare,whilegeneratinganunderstandingoftheirpractices,regulationsandadherencetoqualitystandards.

Methods: Using an exploratory approach, this study is being conducted across all regions inGhana using both qualitative and quantitative methods to solicit for primary and secondaryinformationfromcommunitiesandTMHCswhileadvocatingonmentalhealthimprovementsatthecommunitylevels.

Findings:ThestudyrevealedextraordinarybarrierstoaccessingmentalhealthservicesinGhanaleading to inequality and social exclusion of people living mental disability from basic healthservicesattributedtolackofservicesandsocio-culturalfactors.Preliminaryfindingsrevealedthesignificant role of TMHCs in complementing formal mental health services in Ghana. TMHCsdealswith theperceived spiritualandphysical causationofmentaldisability ledby theprayercamps,traditionalhealers,herbalistsandspiritualtreatmentscentres.Yet,therewaslittleornoregulations for their functions, practices, services and quality of care leading to widespreadconvictionsofabusesandmistreatmentofpeoplewithmentaldisabilityseekingtheservicesofTMHCs.

Discussion& Conclusion: This study concludesby advocating for amulti-sectoral approachbycommunities, researchers, NGOs and the Mental Health Authority to standardize, regulate,developandimprovetheworkofTMHCsinGhana.WeemphasisimprovingaccessandqualityofcaretomakeTMHCsresponsive inprovidingdignifyingmentalhealthservicestoclients.Policylesson from this study will inform knowledge, practices, regulation and policies guiding thepracticesofTMHCsacrosscommunitiesinGhanatocreateavibrantcommunityhealthsystem.

Abstract #3

The Role of the Ghana Health Service in achieving Universal Health Coverage through Integrated Mental Health Services in Ghana

Dr.CynthiaSottie,GhanaHealthService,MentalHealthUnit Introduction & Aim: The Ghana Health Service is a strategic partner towards promotingintegrated mental health services across the Ghana. The Mental Health Department at theInstitutional (Clinical) Care Division of the Ghana Health Service is mandated to coordinate,supervise, monitor and develop both facility and community basedmental health services toimproveaccessibility,availabilityandintegratementalhealthservicesintoPrimaryHealthCare.ThismandatedirectlyoverlapswiththatoftheMentalHealthAuthoritywhoseprimarymandateis to propose, promote and implement mental health policies while providing culturallyappropriate integrated mental healthcare. These mandates intends collaboration of the twoinstitutionstowardsimprovingmentalhealthcareandservicesinthepublicsector.However,ithascreatedduplicationsandconflictsintermsoffunding,accountabilityandresourceallocation.ThispresentationseekstodiscusstheeffectoftheintegratedmentalhealthpolicyontheGhanaHealth Service and advocate for an effective collaborative effort towards achieving the policymandates.


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Methods: This study draws largely from routine quantitative data, documentary analysis andinstitutional policies on mental health across the health sector. Psychiatric OPD services isprovidedacross all the10 regions inGhana,however the casesof theRegional hospitalswithspecializedpsychiatricwingsareexplored.

Findings:ThepreliminaryreviewofthedatashowedthatdespitetheprovisionpsychiatricOPDservices across all the 10 regions and 216 districts inGhana, only three regional hospitals areequippedtoprovidebothOPDandin-patiencementalhealthservices.Otherwise,theremainingregionaladmitandmanagesomecasesofmentaldisordersinthegeneralwards.Atthedistricts,servicesarelimitedtoOPDandcommunitycareactivitiesbyCommunityPsychiatricNursesandCommunityMentalHealthOfficersorPhysicianAssistants inPsychiatry.Meanwhiledueto thelimitedhuman resources, logistical and financial resources and capacity for the general healthproviders,mentalhealthservicesarestillrunningparalleltoprimaryhealthcareandarepoorlyintegrated.

There is also an acute shortage of psychotropic medicines due to the erratic supply system.Fundingtosupportforcommunitymentalhealthservicesisanotherchallengeasistreatmentofmentalhealthworkers.Theyarehighlystigmatisedasmuchastheirpatientsandcarers.

Discussion&Conclusion:Wesuggest thatwhilegovernmentpoliciesonpromoting IntegratedMental Health in Ghana have been targeted towards different institutions and actors in thehealth sector, implementing thesepoliceshavebeen constraintsdue to lackof clarityof rolesandresponsibilities,poorcommunicationandlackofresourcescreatingapracticegap.Thishasimpacted on health workers, service users and service provision overall as a result of lack ofcoordinationandclarityintheMentalHealthActaswellasotherpolicies.

Abstract #4

The Impact of Organizational Support in dealing with Mental Health Issues in the Workplace and at School in Ghana – An Advocacy Call

Dr.GinaTeddy,CentreforHealthSystemsandPolicyResearch,GIMPA IntroductionandAim:Mentalhealthproblemscausedistresstoindividualsandtheirfamilies.InGhana,oneoutofevery fivepeoplesuffer frommentalhealth illness. It isoneof thegreatestsocialandhealthchallengesacrossthecountryyetverylimitedsupportisavailableforsufferers.Mostpeoplewithmentaldisorderstakesolaceinworkandfromtheirsocialnetworkbecauseofthe sense of identity and purpose it creates. Work provide wellbeing for our mental healthbecauseitprovidesasourceof income,senseofidentity,contactandfriendshipwithothers,asteadyorroutinestructureandopportunitiestogainachievementsandcontributetoagoal.Onthecontrary,workor schoolingmayalsohaveanegative impactonourmentalhealthdue toworkplace stress and anxiety, poor relationswith your colleagues, the type ofwork roles andexposure to the elements. If work is causing one to experience hypomania, it becomes astressor.Meanwhile,personswithmentaldisorderarelikelytofacestigmaorbetreatedunfairlybecauseoftheirmentalhealthproblem.AndthisiscausinganxietyforPMD.Thisadvocacycallistocreateawarenessaroundtheissueandgetkeystakeholderstoengageonprovidingsupportformentalhealthattheworkplaceandinschools.

Methods:Anopenforumdebatethroughstakeholderengagementtothegeneralpublicwasthemainmethodfordatagathering.Agroupofpanelistledthediscussionwhichwaslateropenedtotheparticipantstorespondtowithquestionsinformedbyalitereaturereview.Thefeedbackwasrecordedandanalysedtodrawoutthekeymessageforthesettheadvocacyagenda.Similarplatformwillbeusedtoadvocateforinclusivenessinmentalhealthatworkandschools.


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Findings:Thediscussionrevealedthatdespiteemployers’dutytosupportthewellbeingoftheiremployees,verylittleornoprotectionandsupportisbeingprovidedforthewellnessandmentalofemployees.Legislationsareweekornotproperlycontrolled,andreturntoworkaftermentalillnessisvirtuallynon-existentmakingthelivesofsurvivorsdifficult.Also,mostyoungpeopleareexperiencing mental health issues. Some of these young people are struggling with mentalillnesses that many adults deal with, like depression, anxiety, substance abuse, etc. Whethertreatedornot,youngpeoplegotoschool.Andtheproblemstheyfaceturnintomajorproblemsfound in schools. They start with chronic absence, low achievement, disruptive behavior,droppingoutandsuicide.In2017,suicideratesinouruniversityincreaseddramaticallyandtheyweremostlyattributedtomentalillness.Schoolsplayaroleinidentifyingstudentswithmentalhealth problems and help them succeed. But most educators do not have the capacity andresourcestotacklementalhealth.Thosetrainedtodosoareoftendrowninginhugecaseloadswithpoorresources.

Discussion & Conclusion: Provision of mental health services in the workplace highlights theimportanceofworkand inclusiveness.Work institutionsarehardlysupportingtheiremployeesandmostschoolsareneglectingtheirresponsibilitiestowardstheirstudents.Sincemostpeoplespenda largemajorityof their timeat theworkplaceor in schools, these institutionsmustbemandated to provide wellness and mental health support to their employees and studentsrespectively.Aspseudosocial systemsandnetworks, their role inpromotingmentalwellbeingandgoodhealthcannotbeoverlooked.

OS 19 – Securing PHC for all in a voluntary health insurance: lessons from the NHIA-KOFIH collaboration in Ghana

The Ghana National Health Insurance Scheme aims to assure Universal Health Coverage toPrimaryHealthCareforallGhanaians.Ithashoweverstruggledsincepassageofthefirstlawin2003 and commencement of implementation in 2004 to attainUniversal population coveragewithfinancialprotectionto itsdefinedprimarycarepackageforallGhanaians. Aspartof thecollaboration with Korean Foundation for International Healthcare, the NHIA conducted aqualitative and quantitative baseline assessment in the Volta region of Ghana to explore,describe and analyse thewhat,why and howof the challengeswith universal population andfinancial coverage. The voluntary enrolment system was identified as one of the barriers touniversalpopulationcoverage. Itworked insynergywithotherbarrierssuchasserviceaccessand quality as well as the financing gap of the NHIS. Following the baseline study, anintervention to stimulate higher levels of voluntary enrolment was put in place. This panelpresents the findings of the baseline assessment, the intervention to stimulate voluntaryenrolment and the outcomes of the intervention in three presentations of 15 to 20 minuteseach. It is followed by a discussion with a panel of experts on what the way forward is forGhana. The discussion explores how to effectively make enrolment compulsory given thelessons we have learned about the challenges of voluntary enrolment. South Korea hasmanagedtoattaincompulsoryenrolmentanduniversalhealthcoverage,and lessons fromtheSouthKoreanexperiencearepresentedaspartofthepaneldiscussion.Thesessionstructureissummarisedasfollows:

1. Introductorycomments/remarksbythesessionchair

2. Threeinitialpresentationsof10minuteseach(abstractsattached)


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3. Interactions with presenters and a multi-stakeholder panel on ways the increaseenrolmentandenforcemandatoryhouseholdenrolmenttobeabletoachieveUHC.

4. Contributions,questions,discussionandinteractionwiththeaudience(25minutes).

5. Closingsummary/conclusionsandcommentsbySessionChair(5minutes)

Abstract1Title:The“Universal”inUHCandGhana’sNationalHealthInsuranceScheme:policyandimplementationchallengesanddilemmasofalowermiddleincomecountry.

Abstract2Title:EnhancingenrolmentontotheNHIStoachieveUHC:AsurveytoexplorebarriersandenablerstoenrolmentamongNHISmembersintheVoltaRegion.

Abstract 3 Title: The experiment to stimulate voluntary enrolment through expansion ofregistrationunitsandintensifyingeducationofmembersatthedistrictoffice.

Presenters:

1. MariamMusah,SeniorResearchManager,NationalHealthInsuranceAuthority

2. EricNsiah-Boateng,SeniorPolicyManager,NationalHealthInsuranceAuthority

Paneldiscussionmembers:

3. Dr.BaabaSelby,DeputyCEO,Operations,NationalHealthInsuranceAuthority,

4. Professor Irene Agyepong, Ghana Health Service, Research and Development Division,DodowaHealthResearchCenter

5. Prof. Soonman Kwon, Professor, School of Public Health, Seoul NationalUniversity/President,KoreanHealthEconomicAssociation

6. Mr.ChibumShin,Director,Africa-LatinAmericanTeam,KOFIH

7. Dr.YangheeKim,DeputyDirectorofGlobalCooperation,NHISKorea

Enhancing enrolment onto the NHIS to achieve Universal Health Coverage: A survey to explore barriers and enablers to enrolment among NHIS members in the Volta Region

Background: Low enrolment is one of the key challenges for many Social Health InsuranceSystems with voluntary enrolment and Ghana is no exception. UHC requires full populationcoverage. Moreover, ifUHCistobeefficientlyfinancedthroughSHI,theriskpoolneedstobelargeenoughtospreadrisksufficientlyandavoidadverseselection.ItisthereforeimportanttounderstandthebarriersandenablerstoenrolmentandstayingenrolledintheGhanaNHIS.

StudyObjectives:TheobjectiveofthisstudywastodescribeandquantifytheextentofbarriersandenablerstoenrollingandrenewingenrolmentontotheNHIS.

Methods:Thestudydesignwasacrosssectionalsurveyofaprobabilitysampleofhouseholdsinall (17)districtsoftheVoltaregionofGhana.918householdsweresampled. WeadoptedtheGhana Living Standards Survey’s (GLSS6) two-stage stratified sampling design. The samplingframe for the household-based samplewas the list of all delineated 1200 Enumeration Areas(EAs)fromtheGLSS6ofwhich117EAswerefromtheVoltaregionwithcorrespondingdataonnumberofhouseholds.Theregionallyrepresentativesampleofhouseholdsforthesurveyintheregionwasbasedonatwo-stagestratifiedclusterdesign.Inthesurvey,wecollectedinformation


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on health service utilization, general health and health seeking behaviour, knowledge of theNHIS,willingness to pay for theNHIS premiums, anthropometry, demographic and householdcharacteristics.

KeyFindings:50%ofhouseholdrespondentswereactive(validcardbearingmembers)andtherest were inactive (unenrolled and non-renewed). Active members were more likely to havehigher formal education (P=0.000), more knowledge on NHIS processes/benefits package (P=0.000)andliveclosertotheNHISdistrictofficethantheirinactivecounterparts(P=0.000).Thesefactorsfacilitatedenrolmentandstayingenrolled.Activemembersalsoratedtheirhealthstatusandselectedself–reportedhealthconditionstobemuchpoorerthantheunenrolledpopulationpointingtothephenomenonofadverseselection.95%oftheinactiverespondentswerewillingtoenrollwhile99%oftheactivemembershipwerewillingtocontinuewiththeirenrolment.

Conclusions:TheresultssuggestthatfortheNHIStoincreaseenrolmentandultimatelyachieveUHC,itmustreviewitsenrolmentandeducationprocessestoenableeasieraccesstothedistrictscheme offices and a better understanding of enrolment processes. Mandatory householdregistrationwillalsobeneededtocurbadverseselection.

The “Universal” in UHC and Ghana’s National Health Insurance Scheme: policy and implementation challenges and dilemmas of a lower middle income country

Agyepong I.A., Abankwah D.N.Y, Abroso A., ChangBaeChun, JosephNiiOtoeDodoo, ShinyeLee,SylvesterA.Mensah,MariamMusah,AdwoaTwum,JuwhanOh,JinhaPark,DoogHoonYang,KijongYoon,NathanielOtooandFrancisAsenso-Boadi(2016)BMCHealthServicesResearch.

Background:Despiteuniversalpopulationcoverageandequitybeingastatedpolicygoalof itsNHIS,overadecadesincepassageofthefirstlawin2003,Ghanacontinuestostrugglewithhowto attain it. The predominantly (about 70 %) tax funded NHIS currently has active enrolmenthoveringaround40%of thepopulation.Thisstudyexplored in-depthenablersandbarriers toenrolment in the NHIS to provide lessons and insights for Ghana and other low and middleincome countries (LMIC) into attaining the goal of universality in Universal Health Coverage(UHC).

Methods:WeconductedacrosssectionalmixedmethodsstudyofanurbanandaruraldistrictinoneregionofSouthernGhana.Datacamefromdocumentreview,analysisofroutinedataonenrolment, key informant in-depth interviews with local government, regional and districtinsurance scheme and provider staff and community member in-depth interviews and focusgroupdiscussions.

Results: Population coverage in theNHIS in the study districtswas not growing towards nearuniversalbecauseoffailureofmanyofthosewhohadeverenrolledtoregularlyrenewannuallyas requiredby theNHISpolicy. Factors facilitatingandenablingenrolmentweredrivenby thedesigndetailsoftheschemethatemanatefromnationallevelpolicyandprogramformulation,frontlinepurchaserandproviderstaffimplementationarrangementsandcontextualfactors.Thefactorsinter-relatedandworkedtogethertoaffectclientexperienceofthescheme,whichwerenotalwaysthesameasthedeclaredpolicyintent.Thisthenalsoaffectedthedecisiontoenrollandstayenrolled.

Conclusions: UHC policy and program design needs to be such that enrolment is effectivelycompulsory in practice. It also requires careful attention and responsiveness to actual andpotential subscriber, purchaser and provider (stakeholder) incentives and related behaviourgeneratedatimplementationlevels.


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Keywords: Universal Health Coverage, Policy, Implementation, National Health InsuranceScheme,Ghana,Lowandmiddleincomecountries.

The experiment to stimulate voluntary enrolment through expansion of registration units and intensifying education of members at the district office

Background: The findings from both the qualitative and quantitative studies informeddevelopment and evaluation of a two component intervention for increasing voluntaryenrolment.ThetwocomponentsoftheinterventionwereRegistrationUnitExpansionandNHISInformation and Education. The ultimate objective of the two interventions was to increaseenrolmentamongresidentsintheinterventiondistrictsthrough:

1. IncreasedknowledgeabouttheNHIS,itsenrolmentprocessesandthebenefitspackagethrougheducationandcommunication.

2. Encouragementof‘groupregistration’anddiscouragingindividualregistration.3. Takingregistrationclosertothepeople

StudyObjectives:TheobjectiveofthestudywastoevaluatetheimpactoftheinterventionsonvoluntaryenrolmentintheNHIS.

Methods: The study designwas a quasi-experimental pre-test post-test control groupdesign.Twodistrictswererandomlyselectedoutofthe17districtsintheVoltaRegiontopiloteachoftheinterventionsrespectivelyandonedistrictwasselectedasacontrolforcomparison.Kadjebidistrict implemented the Registration Unit Expansion intervention while Ketu North districtimplementedtheNHISInformationandEducationintervention.NorthTonguwasselectedasthecontrol district.In each of the three districts, before and after routine enrolment data wascollected and analyzed for comparison. The interventionswere run concurrently for 9months(25thOctober2016-31stJuly2017)afterwhichenrolmentnumbersfromthethreedistrictswereanalysed. Administrative data (routine enrolment data) during the intervention period wascomparedenrolmentdata9monthspreintervention(25thOctober2015-31stJuly2016).Key Findings: Analysis revealed decreases in enrolment rates across all the three districtsreflectiveofthenationaltrendsince2012.Theratesofdecreaseintheinterventiondistrictswasslowerthaninthecontroldistrict(P<0.001).Thismeansthatduetotheinterventions,Kadjebi’senrolmentratewas7%lessthanNorthTongu‘swhileKetuNorth’senrolmentratewas5%lessthanthatofNorthTongu,implyingthatintheabsenceofthetwointerventions,enrolmentratesinbothKadjebiandKetuNorthdistrictswouldhavedeclinedata ratesimilar to thatofNorthTongu.

District Before After Difference

NorthTongu 40.1% 28.6% 11.4%

KetuNorth 35.7% 29.4% 6.4%

Kadjebi 44.2% 39.7% 4.4%

Conclusions:Althoughtherewasageneraldecreaseinenrolment,theintervention“RegistrationUnit Expansion” performedbetter than the interventionon ‘NHIS Information and Education’.However it still did not bring enrolment close to the desired levels of universal. It will beimportant to find interventions that effectively make enrolment compulsory rather thanvoluntary.


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Economics of Public Health: Implications for research practice in Africa NanaAnokye,**DrJusticeNonvignon:*BrunelUniversityLondon,HERG-**DepartmentofHealthPolicy,PlanningandManagement,SchoolofPublicHealth,UniversityofGhana,Legon

Current worldwide health trends present an alarming picture of widening disparity in healthglobally. In low andmiddle income countries (LMIC), healthcare systems are now faced withincreasingburdenofNCDs inaddition toaddressingahighburdenof communicablediseases.Noncommunicablediseases(NCDs),astheresultoflifestylebehaviour,areontheriseinhigh-incomecountries.Globally,averagelifeexpectancyatbirthhasincreasedfrom67in2000to72years in2016.However, thereexistsa significantvariation in lifeexpectancybetweenregions,forexample,62yearsinAfricaand78yearsinEurope(WHO2018).

These trendspresent complex challenges for global andnational health systems. Inparticular,this necessitates innovative but policy and context relevant approaches to ‘describe healthproblems,identifyandhelpdecisionmakerssetpriorities’(WHO2017).However,suchevidencebase in global health, particularly in economics, is scarce and fragmented. This is partiallyattributabletomethodologicalchallengesassociatedwitheconomicresearchinpublichealth.

In this proposed session, a collection of three papers that present various policy relevantmethodologicalapproachestodealingwithchallengesintheeconomicsofphysicalactivity.ThesessionwillhighlightcurrentresearchpracticesandnewfindingstoinformresearchpracticeinAfrica and the formulation of cost-effective programmes and policies. It will provide aninternational platform to share views and debate complex research challenges facing globalhealth.

References

WHO(2018).Globalhealthobservatorydata.Geneva,WHO2018.

WHO(2017).10factsonthestateofglobalhealth.Geneva,WHO2017.

Incorporating demand in economic evaluation of public health interventions: case study of an augmented exercise referral scheme using web-based behavioural support

AnokyeN11HealthEconomicsResearchGroup,DepartmentofClinicalSciences,BrunelUniversityLondon.

Reflecting the diversity in a population is essential tomaximising the efficiency gainable frompublic health interventions. However, to date, economic evaluationmethods of public healthinterventions rarely account for characteristics that influence the uptake and sustainability ofinterventions (e.g.age,gender,health status).Buildingon themethodsofa cost-effectivenessanalysis of an augmented exercise referral scheme, the presentation uses an innovativeindividuallevelsimulationapproachtomodelcosteffectivenessanddemonstrateshowdemandcouldbemergedwitheconomicevaluationaspartofamulticentreRCT.

Theanalysesweretwo-fold–shortterm(within-trial)cost-effectivenessanalysis(frombaselineto 12 months post randomisation) and long term cost-effectiveness analysis (individual levelsimulationmodellingof long termexpectations forcost-effectiveness), foraugmentedexercisereferral scheme using web-based behavioural support against standard exercise referralscheme.Healthcareprovider,personalsocialservices,andpatientperspectiveswereused.Thesimulationmodelallowsindividuals’toexperienceevents(e.g.uptakeofPAintervention,onsetof heart disease, diabetes, depression) at times in their lifetime that are influenced by their


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characteristics and activity levels. Data used to populate themodel parameters were derivedfrombestevidencereviews.Themodel isbasedonanexistingpolicyrelevantanalyticalmodel(has informed3publichealthguidelines inUK).Theshorttermcost-effectivenessanalysisusesresource use data for development of training for LifeGuide coach, and technician; web andexercise support (e.g. duration and frequency) provided by technician; LifeGuide coach andhealth professionals respectively; provision and running of the exercise sessions at leisurecentres;andhealthandpersonalsocialserviceuse.

ThemainoutcomeoftheeconomicanalysisisanincrementalcostperQuality-AdjustedLife-Year(QALY-basedonEQ5D5L).ThecasesofCVD/diabetes/depressionavoidedisalsoreported.Costsarepresentedseparately,fordifferentperspectives(e.g.healthcareprovidersandparticipants)andbrokendown into threecategories:programme-level costsofaugmentedexercise referralscheme;patient-levelcostsofthescheme;andsavingsfromavoidedtreatment.Theuncertaintyaround results is presented using the cost effectiveness: plane and acceptability curve. Thediscussionhighlights the considerations foradapting theeconomicmodel toanalyse thevalueformoneyofinterventionsinAfrica.

Assessing cost effectiveness of multinational and factorial trials: internet-based training for primary care clinicians on antibiotic prescribing for acute respiratory-tract infections

OppongR22HealthEconomicsUnit,InstituteofAppliedHealthResearch,UniversityofBirmingham. This study highlights some of the challenges associated with the economic analysis ofmultinational and factorial trials as well as those associated with the economic evaluation ofinterventionsthatconsiderantibioticuse.

Overprescribing of antibiotics by general practitioners is seen as a major driver of antibioticresistance. Training general practitioners in communication skills and C-reactive protein (CRP)testingbothappeareffective inreducingsuchprescribing.However, thecost-effectivenesshasnot been determined. This study assesses the cost-effectiveness of (i) training generalpractitioners (GPs) in the use of CRP testing, (ii) training GPs in communication skills and (iii)trainingGPsinbothCRPtestingandcommunicationskillscomparedtousualcare.

Economicanalyses(cost-utilityanalysis(CUA)accountingforthecostofantibioticresistanceandcost-effectiveness analysis (CEA))were both conducted from a health care perspectivewith atimehorizonof28daysalongsideamultinational,cluster,randomised,factorialcontrolledtrialin patients with respiratory tract infections in five European countries. The primary outcomemeasureswereQALYsandpercentagereductionsinantibioticprescribing.Hierarchicalmodellingwas used to estimate an incremental cost-per-QALY-gained and an incremental cost-per-percentage-reductioninantibioticprescribing.

Overall,theresultsofboththeCUAandCEAshowedthattrainingincommunicationskillsisthemostcost-effective.However,excludingthecostofantibiotic resistance intheCUAresulted inusual care being the most cost-effective option. Country-specific results are also presented.Internet-based training in communication skills is a cost-effective intervention to reduceantibiotic prescribing for respiratory tract infections in primary care if the cost of antibioticresistanceisaccountedfor.

Evidence synthesis for decision making: The methods or methodological issues? The case for willingness-to-pay criterion validity assessments

KanyaL33DepartmentofHealthPolicy,LondonSchoolofEconomicsandPoliticalScience


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The importance of evidence syntheses in highlighting and quantifying the magnitude of thebenefitsandcostsofvariedinterventionsisacknowledged.Thisaidsdecision-makingrelatingtothe acceptability, affordability and feasibility of interventions and policies and ultimately,resourceallocationdecisions.Despiteitslimitedapplicationinhealth,costbenefitanalysisusingwillingnesstopay(WTP)techniquesisapowerfultoolforassessingdirectlyboththecostsandbenefits of interventions, summarising bothmetrics inmonetary terms.WTP estimates couldprovide credible price signals useful for decision making on investment and subsidy levels,dependingon thehealth systemcontext. In anenvironmentofdwindling resources forhealthcare, thosewhoarewilling topay forservicesshouldbeaccordedtheopportunity topayataprice that is affordable to themwith adequateprotectionmechanisms inplace for thosewhoneedthem.

TheuptakeofWTPsurveysinCBAanalysis isoftenmetwiththeconcernsaroundthecriterionvalidityofestimates.ThispresentationpresentsanexhaustivesynthesisofWTPstudiesacrossdifferentsectors.Whilestandarddatabasesearchmethodswereemployedtoretrievearticles,themajoritywereobtainedthroughreferencelistandauthorsearches.Arandom-effectsmeta-analysiswaspossibleonlyforaproportionofthearticles.Challengeswiththeremainingarticlesincluded incomplete,mixed reporting of estimates hindering comparisons and in some cases,non-standardisedreportingofestimates.

While critics of themethod cite the potential lack of criterion validity ofWTP estimates, thereviews highlight methodological issues with the conduct and reporting of such assessments.This includesvariety in the termsused todescribecriterionvalidityassessmentsand, thedatacollected and reported for a range of important attributes that could inform the synthesis ofestimatesfromsuchanalysesandconclusionsthereof.Severalempiricalassessmentshavebeendonesincethelastsynthesisofcriterionvalidityassessmentswasconductedmorethanadecadeago. However, there does not seem to have been notable growth in the methods used toconductbothWTPandcriterionvalidityassessments,andinthereportingofsuchfindings.

Basedon the findingsof this review,acase ismade for thedevelopmentofguidelines for theconductandreportingofcriterionvalidityassessmentsinhealth.Aguidedskillsbuildingsessioninvolvingparticipantsattheorganisedsessionwillbeusedtodeliberateonwhatthesemaylooklikeforcriterionvalidityassessments,withbroadapplicationsforotherempiricalstudies.


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OS 21 – Sexual reproductive health and rights: a smart investment towards achieving SDGs by 2030

Session Chair: Chinwe Ogbonna, Head Middle Income Country Hub, UNFPA East and Southern AfricaRegionalOffice.

SessionObjectives:

– Global, continental, regional and national investments for effective coverage of acomprehensive minimum benefit package of care, financing SRHR, financial riskprotection for vulnerable population groups through pro-equity type schemes andpromotingclientsatisfaction.

– Secure interest for participation of African health economists on SRHR related workstreamsin2019andbeyond

Methodology: The plenary session will adopt a moderated panel discussion in plenary andinteractivesessionwithinterventionsfromtheaudience.

Structureofsession:

PartI:Thesessionisplannedforoneandhalfhrs:

– (5mins)administrativeannouncements– (5mins)IntroductionbySessionChair– (50mins)eachforPanelists

o Costing, Investment cases and financing SRHR Transformative results: A globalandcountryapproach;DrHowardFriedman,UNFPATechnicalSpecialist,UNFPAHeadquarters

o Inclusion of FP and ASRH in the benefit package of Ghana’s National HealthInsurance;rationale,methodologyandexpectedresults,GhanaHealthService

o ACountryInvestmentcasetowardssecuringUniversalaccesstoSRHR– (25 mins), facilitated discussions with the audience, featuring question and answer,

comments,contributions,etc.– (5mins),ClosingstatementbytheSessionChair


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ParallelSession7–OralPresentations

Parallel Session 7-1 Resource allocation, efficiency and management 1

Assessing the Effect of Performance-Based Financing (PBF) on Health Care Quality in Nigeria: Experiences from Nigeria State Health Investment Project (NSHIP) Implementing States

MashinMuhammad1MichaelC.Ajuluchuku,SeniorMedicalOfficer1MuhammadMashin,PrincipalPlanningOfficer1BintaIsmail,NationalProjectCoordinator1IsmailN.Salihu,SeniorMedicalOfficer1NdidiF.Ijeh,SeniorPlanningOfficer(SPO)1ChidinmaPaul-Iyaji,SeniorPlanningOfficer(SPO)11NationalPrimaryHealthCareDevelopmentAgency(NPHCDA) Introduction:Healthsystemsaremeasuredbythepopulationhealthindicesaswellasqualityofcareprovided.Between2000and2010,theNigerianhealthsystemoccupiedthirdtotheworstperformed health systems in the World. These poor health indices resulted to the countrymissingtheMNCHMDGstargets.ThediagnosticoftheNigerianhealthsystemrevealedseriesofsystemicproblemsincludinghighfragmentation/poorcoordination,lowincentives,lowtechnicalefficiency, chronic stock-outsof essential drugs, dilapidated infrastructure/equipment and lackofsystematicmeasureofhealthcarequalityandsystemperformance.Asasteptoaddressthesesystemic problems, Nigeria is using a credit from theWorld Bank to implement Nigeria StateHealth Investment Project (NSHIP) with focus on performance-based financing (PBF) in threeStates which has introduced series of measures including quantified systematic measure ofquality/project performance review, institutional coordination, autonomy at all levels ofimplementation,andstrengtheningofexistingsystems.ThisstudythereforeassessedtheeffectsNSHIPonqualityofhealthcareinNigeriaandevaluatingtheroleofPBFprinciplesinenhancingcoordinationmechanisms.

MaterialandMethods:Thestudyusedmixedresearchmethodsinwhichprimaryandsecondarydata sources were collected for analysis. The secondary data were obtained from the NSHIPportal while the primary data include interviews with stakeholders involved in the NSHIPimplementation. Simple descriptive statistics and qualitative methods were used for dataanalysis.

Results:Thestudy foundapositive influenceofNSHIPon thecoordinationmechanisms in theimplementingStates.Theunderstandingofqualityofcareconceptspreadacrossfrontlinehealthworkersanddataanalysisalsorevealedimprovedqualityofcarefromaverageof25%toabout70%.Thelowdiscordancefromcommunityclientsatisfactionsurvey(CCSS)resultsalsoshowedconsistencyinqualityofhealthcareandimprovedprovider-patientrelationships.

Discussions/Conclusion: The introduction of NSHIP has influenced the implementing States inseveralways.TheNSHIPStatesadoptedPBFdataverificationmodelforverifyinghealthfacility


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register informationbeforeuploading intonationaldata instance.ThethreeStateswerefoundtobewell informedaboutqualityofcare.Consequently,patientcare/respectandtrackinghasimproved.Moreso,thePBFhasenhancedclearseparationsoffunctionsamongkeystakeholdersatalllevelsofimplementation.ThestudyrecommendedthatthereisneedforexpansionofPBFtomoreStatesinordertoturnaroundpopulationhealthindicesinNigeria.

Can performance scorecards promote community involvement in regulatory enforcement? A process evaluation of an innovative regulatory intervention in Kenya

IreneKhayoni,StrathmoreUniversityNairobi

Background: Many low- and middle-income countries recognize the limitations of traditionalcommandandcontrolapproachestofacilityregulation,leadingtotheemergenceofinnovativemodels,includingresponsiveregulatorystrategies,andincreaseduseofinformationtechnology.However,thefocusofregulatoryinnovationslargelyremainstheproviders.Littleefforthasgonetowardsdevisingmodelsthatincorporateserviceusers.InKenya,theMinistryofHealthandtheregulatory agencies developed and piloted a risk-based regulatory regime called the KenyaPatientSafety ImpactEvaluation (KePSIE),which involved intensified inspectionsusinga singlecomprehensive checklist. A key innovation was the display of performance scorecards athealthcare facilities. These scorecards gave facilities a rating on inspection performance of A(highest), B, C or D, and provided guidance on interpreting these scores. We conducted aqualitativestudytoexploretheimplementationandperceivedimpactofthepubliclydisplayedscorecards.

Methods: The study was conducted in the three KePSIE pilot counties (Kakamega, Kilifi andMeru) using a qualitative approach. We conducted in depth interviews with health facilityworkers, inspectors, patients, community representatives from health facility and communityhealth committees to obtain a broad community perspective. Interviews were recorded,transcribedandanalysedusingtheFrameworkApproachinNVIVO.

Results:Majorityofcommunityrepresentatives,patientandhealthfacilitycommitteemembershad not seen or understood the score card despite them being nearly always displayed atfacilities.Thescorecardfailedtoreachthetargetaudience,butmosthealthfacilityworkerswerebotheredbythemandfeltmotivatedtocomplywiththebasicminimumstandards.

While some felt that thescorecardscan influencepatients’ choiceof facility,majority felt thatfacilityscoreswouldnotinfluencepatients’facilitychoiceduetogeographicalaccesschallenges.

Conclusion:Scorecardsareanimportanttoolthatcanbeusedtoencouragehealthfacilitiestocomply to thebasicminimumsafety standards. In this case, theclearmajorityofpatientsandcommunityrepresentativesweinterviewedhadnotseenthecardsandcouldn’tinterpretthemcorrectly even when we showed them. As such it would be beneficial to involve communityhealthvolunteersabitmoreineducatingthepublicaboutthescorecardsastheyappearedtobemoreenthusiastic.

Patterns and appropriateness of surgical referrals in Malawi

PittalisC,MwapasaG,GajewskiJ

Background:ConditionsamenabletosurgeryareagrowinghealthburdeninMalawi,particularlyinruralareaswhereaccess tosurgicalcarecontinuestobegreatly inequitable.Qualitydistrict


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level health services and well-functioning referral networks for advanced care at higher levelfacilities are critical to ensure adequate access to life-saving surgery for rural populations.However,thecurrentreferralservicesinMalawiareweakandnotwellstreamlined,leadingtoasub-optimalutilisationofpublicresources.

Aimsandobjectives:TheaimofthisstudywastoexaminesurgicalcasescommonlyreferredtoQueenElizabethCentralHospital (QECH) inBlantyre, the largesthospital inMalawi, tocapturereferralpatternsandtoidentifyinefficienciesinthereferralsystem.

Methodology: Data on inter-hospital surgical referrals to QECH was collected prospectivelyduringtheperiodJanuary2014-December2015,usingpatientchartsinsurgicalwards.Referralsfromalllevelhospitalswereincluded.Self-referralsandpatientssentbyfirstlinehealthservices(i.e. health centres and community hospitals) were excluded. Descriptive statistics werecalculated using SPSS. A representative sub-sample of 257 referrals (20% of the full studysample)wasassessedforappropriatenessandquality.

Results:QECHreceivedatotalof1380surgicalreferralsduringthestudyperiod,withanaverageof58permonth.59%weremalepatients.80%werereferredbygovernmentdistricthospitals.Thetopthreesurgicalconditionsreceivedweretumours(24%),gastrointestinalconditions(22%)and congenital abnormalities (11%). The analysis of appropriateness done on a sub-sample ofcases(n=257)revealedthatapprox.1in3caseswerereferredunnecessarily.Inthemajorityofthesecases (n=85)thetypeandseverityof theconditionscouldhavebeenmanaged locallyatthe district hospitals and the referrals were not justified by special circumstances affectingserviceprovision(e.g. lackofessentialequipment,suppliesorpersonnel). Inover80%ofcasestherewasnocommunicationwithQECHpriortoreferral,and41%ofcasesweremisdiagnosedorhadincompletediagnosesbythereferringclinicians.40%ofcaseswerenotreferredtimely.

Conclusion:Referralprocess improvements, includingbettercommunicationbetweenreferringand referralhospitals,areurgently required to improveaccess to timely surgical care for ruralpopulations.Thiswill leadtobetterutilisationofpublicresourcesand,ultimately,effectivenessandresponsivenessofthewiderhealthcaresystem.

Street level bureaucrats: malaria in pregnancy policy implementation in nine Ghanaian health facilities

MatildaAberese-Ako,UniversityofHealthandAlliedSciences

Introduction:Malaria in pregnancy continues to be a debilitating disease and governments insub SaharanAfrica continue tomake efforts to prevent andmanage it in order to reduce thenegative outcomes. Currently interventions such as ITNs, IPTp and treatment of malaria inpregnancy have been implemented in Ghana. Using ethnographic study methods, this studysought to understand dynamics of health care provision and response from pregnantwomenutilizingmalariainterventionsinninehealthcarefacilitiesinGhana.

Methods: The study employed ethnography through in depth interviews, case studies andobservations inantenatal clinics in fivegovernmenthealth facilitiesand threeChristianHealthAssociation facilities for a period of ninemonths in twoGhanaian regions.Observationswerealso conducted in pharmacies and laboratories in the health facilities. Additionally, interviewswereheldwithhealthproviders,administrators,pregnantwomenandcommunitygatekeepersto understand how health care is organized. All ethical procedures were followed. Data wastriangulated and analyzed using grounded theory approach. The results are based on theoutcomeoftheanalysis.


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Results:Theresultssuggestthathealthfacilitiescopedwithfailureofgovernmenttoreimbursethemforcostincurredintreatingclientsandfrequentstockoutsofdrugsandmedicalsuppliesbypassingthemtoclients,throughchargingfeesforfee-freehealthservices. Insuredpregnantwomen paid 50% of cost of ANC services, routine drugs, malaria treatment and lab tests.Uninsured women paid full cost of all health services. Both insured and uninsured pregnantwomen paid full cost of sulphadoxine-pyrimethamine (SP) for the prevention of malaria inpregnancyinsevenofthefacilities.Theconsequenceswasthatthehealthfacilitieswereabletomaintaintheirstocksandtokeeptheirfacilitiesrunning.However,agoodnumberofclientswhocouldnotpayforserviceswerenotunabletoaccesshealthcare.Forsuchclientsthischallengecontributedtodefaultsandinabilitytopayforlaboratorytestsuchasmalariainpregnancytest,which sometimes frustrated health care providers, as it impeded their ability to make goodclinicaldiagnoses.

Conclusion:Politicalinterestneedstobebackedbycontinuedsupportfromthegovernmenttogovernment and CHAG facilities ensure that resources are adequately provided to healthfacilitiestoenablethemprovidecriticalcaretopregnantwomen,ifmalariainpregnancyandthenegativeconsequencesistobecontrolled.Otherlessonsarealsodrawnfromthisstudy.

Towards primary health care for all in Ghana: mapping and assessing the capacity of health facilities in Central region

FrancisM.Asenso-Boadi*1,AugustinaKoduah2,YorikoNakamura3,LydiaBaabaDsane-Selby1,TitusSorey1,EmmanuelBaah-Dankwah1,HabakkukTarezina1,ChrisAtim3,DanielA.Arias41NationalHealthInsuranceAuthority,Ghana2SchoolofPharmacy,UniversityofGhana3ResultsforDevelopment4TheJohnsHopkinsBloombergSchoolofPublicHealth

Introduction:TheGovernmentofGhanaisworkingtoensureequitableaccesstoqualityprimaryhealth care (PHC) services to allGhanaians. To achieve this, it is important to find answers toquestions such as where provider are, what services they provide and potential gaps in theircapacity toprovideclinicalandnon-clinical services.Since2014, theNationalHealth InsuranceAuthority (NHIA), in collaboration with Ghana Health Service (GHS) and a consultant hasconducted provider-mapping exercises to answer these questions, in the Upper East, UpperWest,Volta,AshantiandCentral regions.Wewill focusonfindings fromtheprovidermappingexerciseconductedintheCentralregionbetweenMayandAugust2018.

Methods: Amulti-stakeholder technical steering committee revised anexistingdata collectioninstrumentlookingatthecompositionofabasicPHCpackageandsetofcriteriaaroundstaffing,equipment, catchment area and hours of operation to deliver this package. A teamof districthealthinformationofficers,NHIAofficersandanHFGconsultantundertooktheexercise.

Results: The exercisemapped 1,093 clinical and non-clinical health facilities in Central region.Community-basedHealthPlanningandServices(CHPS)madeupthemajorityofclinicalproviders(63 percent) followed by health centres (15 percent) and these are a critical part of thepopulation’saccesstoPHC.Therearehowever,gapsinhumanresourcescapacitytodeliverPHCbecause when Level 1 staffing capacity criteria (i.e. presence of at least a medical assistant,nurse,dispensingassistantandcommunityhealthofficer)areapplied,only6percentofclinicalprovidersmeet thecriteriaandcouldserveasstand-alonePHCproviders.NoCHPScompoundmeetsthesecriteria.Similarly,whenLevel2staffingcapacitycriteria(i.e.presenceofatleastamedical assistant and community health officer) are applied, 46 percent of clinical providersmeetthecriteriaandcouldserveasstand-alonePHCproviders.Essentialequipmentneededfor


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primaryhealthcare is lackingasonly18percentof clinicalhealth facilitieshave the full setofequipmentconsiderednecessarytodeliverPHCservices.

Conclusion:TheprovidermappingexerciseintheCentralregionprovideanimportantbaselineset of evidence to inform PHC services and efforts towards universal health coverage. Thisinformationislikelytobedynamicandcriticalforservicesdeliverypolicymakingprocesses,andthereforeneedstobeupdatedregularlytotrack investmentsmadeinthehealthsectorandingeographicareaswiththegreatestneedandmostseveredeficits.

Making supervision Supportive and Sustainable in Primary Health Care Services in Nigeria

Ezinna Enwereji,AbiaStateUniversity

Introduction:ThebenefitofsupervisioninmanaginghumanresourcesinPrimaryHealthCareisoften not achieved in developing countries including Nigeria. Supervision services havetraditionally emphasized on administrative issues such as inspection of facilities , use ofresources,supplyoflogistics,reviewofrecordsandcommunicationofinformationfromhighertolowerlevelswithoutregardtofacilitation.Supervisorsusuallyblameindividualsratherthanlookforrootcausesindeficientprocesses.Forthisreason,traditionalsupervisionsystemshavenot sufficiently ‘empowered staff to engage in problem solving or to take initiative inimprovingservicequalityandaccesstoclients.

Objective: Thepaperaims to identify gapsand limitations militatingagainst supervision inprimaryhealthcare.

Materials and method: The study observed and documented gaps in supervision styles inprimaryhealthcarecentresinAbiaState.Dataweregeneratedbyreviewofrelevantliteratureandworkexperiences.Atwo-dayonthejobtrainingwasprovidedforthesupervisees.Trainingemphasizedself-assessment,peerassessment,communityinputtochangesupervisionfrominspecting facilities and gathering service statistics to concentrating on theperformance ofclinicaltasksandresolutionofproblems.Analysisoffindingswasqualitatively.

Result: The followingswere identifiedas the systemicproblems that plagued effectivesupervisioninprimaryhealthcarecentres.Theseinclude:

o • lackofplanningand/ortrainingofstaffo • failuretodefineprioritiesinservicesprovidedo • shortageofresources(man,materialsandfinance)o • episodicvisitsofsupervisorso • staffnon-adherencetoworkethicso • diversionofresourceso • lackoffinancialstabilityo • lackofaccountabilityando • lowmoraleamonghealthworkersduetopunitivemeasures

Thestudyfoundthatfacilitatingonthejoblearningpromotedqualityhealthcareservices,highstandardteamworkandincreasedthehealthworkers’problem–solvingtechniques.

Conclusion: On the job training both formal and informal whether in one-on-onemeeting, inpeerdiscussion,andinmeetingsoutsidetheworkplacewillenhancesupportivesupervisionandenablehealthworkerstoreviewtheirperformancesagainststandards.


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Parallel Session 7-2 Non Communicable diseases

Barriers and opportunities for NCD management in Primary Health Care: Lessons from a clinical workflow analysis in diabetes and hypertension clinics

CarolineGitonga1,SarahKedenge1,AliceTarus1,AlbertOrwa1,CarolineKyalo1,EddineSarroukh1.1PhilipsResearchAfrica

Non-communicable diseases (NCDs) are the leading cause of death globally. In 2015, NCDsaccounted for 39.8 million (71.3%) of the 55.8 million deaths reported globally. In recentdecades, low and middle income countries (LMICs) have experienced an epidemiologicaltransition frommajorityofdeathsanddisabilitybeingcausedbycommunicablediseasestoanincrease inNCDdeaths.The inabilityof thehealthsystems in theLMICstocopewiththeNCDburden is evident as higher rates of premature deaths from NCDs. Response to the NCDepidemicinLMICswillneedstructuredNCDservicesattheprimaryhealthcare(PHC)level.

Toexamine the readinessof thePHC facilities toofferNCDservicesand identifyopportunitiesforNCDmanagementinPHCfacilities,weundertookanassessmentoftheclinicalpracticesandclinicalworkflowsintheoutpatientclinicsfordiabetesandhypertensionin3PHCfacilitiesand3higherlevelsfacilitiesinKiambuCountyinKenya.Resultsfromtheanalysisshowedthefacilitieslacked policies on NCDmanagement at the PHC level, experienced frequent drug stock-outs,lacked information on management of the conditions at the PHC level and the healthinformation systems were insufficient or absent for the documentation of the NCD data.AdditionallythefacilitieswereunderstaffedwithhighworkloadintheNCDclinicsandthestafflackedspecializedtraininginNCDmanagement.ThestudyidentifiedbarriersandopportunitiesinimprovingdiabetesandhypertensionmanagementatPHClevel.

Socio-economic correlates with the prevalence and onset of diabetes in South Africa: Evidence from the first four waves of the National Income Dynamics Study

VelenkosiniMatsebula,VimalRanchhodSALDRU,UCTWe make use of multiple waves of National Income Dynamics Study data to investigate thesocio-economic factors that correlatewith the prevalence and onset of diabetes.Our analysisfollowsacohortof3470olderadultsagedfortyandabove,whoareinterviewedfourtimesoverasixyearperiod.Weuselinearprobabilitymodelsandestimatethelikelihoodofdiabetesasafunctionofage,race,gender,education,income,exerciseandobesity.Ourprimaryfindingsarethatageandobesitycorrelatestronglywithdiabetes,whileincomedoesnothaveastatisticallysignificanteffect,conditionalontheothercovariates.Ourregressionestimates indicatethatofindividuals who reported not being diabetic inWave 1, those who were obese andmorbidlyobese were 12.9 and 16.7 percentage points more likely to have experienced the onset ofdiabetes respectively, relative to thosewith a BMI in the healthy range. In addition, frequentexercisedoesappeartohaveaslightprotectiveeffectagainsttheonsetofdiabetes,andthereissomeevidencethatbettereducatedpeoplehavealowerriskofonsetofthedisease.


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Cost of accessing diabetic care services in Iganga district, Eastern Uganda.

ElizabethEkirapa-Kiracho,DavidGuwatudde,BirgerForsberg*MakerereUniversitySchoolofPublichealth,**KarolinskaInstitute

Introduction: Patients in low income countries often incur high costs when accessing healthservices. Thismay influence adherence to treatment among diabetic pateints leading to poorbloodglucosecontrol.

Aim: This study aimed at estimating the economic cost of diabetic care from the patient’sperspective.

Methods:Aningredientsapproachwasusedtoestimatedirectandindirectcosts.Thedatawascollectedthroughexitinterviewswith130diabeticpatientsduring10clinicvisits.Acostanalysiswasundertakenusingdescriptivestatistics.

Results.Theaverageannualcostofdiabeticcareperpateintwas280USD.Themaincostdriverwasmedication.Eightysixpercent(113)oftherespondentsreportedtohavepaidsomemoneyatthediabeticclinicmainlyforbloodglucosetests(84%).Meandistancetotheclinicwas12.6km.Seventythreepercentoftherespondentsregularlypurchaseadditionalmedicationfortheirdiabetictreatmentfrompharmacies.Themainsourceoffundingformeetingdiabeticcarecostsweremainly personal savings (47.7%) and familymembers (66%). Sixty two percent reportedthattheyhadeverfailedtotaketheirdiabeticmedicationinthepastthreemonths.

Conclusions.Patients incurhighcosts in theprocessofseekingdiabeticcare.Themain factorsthathinderaccesstocareincludethehighcostofdiabeticmedicationandlongdistancestothediabeticclinic.

Recommendations. Government should reduce out of pocket expenditure on diabetes byincreasing the quantity of diabetic drugs and blood glucose test kits to health facilities andprovidingdiabeticmedicationatlowerlevelfacilities.

Evidence-based Priority Setting for NTDs: How Return on Investment Analysis Supports Sustainability of Lymphatic Filariasis programme in Ghana. KingleyAddaiFrimpong,SchoolofPublicHealth-UniversityofGhana Background:Lymphaticfilariasis(LF)isadiseasefoundinthetropicalandsubtropicalregionsofthe world, where it is a major public health problem. It is caused by the helminth parasitesWuchereriaBancroft,Brugiamalayi,andB.timori,andistransmittedbymosquitoes.TheGhanaLFprogrammehasmadesignificantprogress towards the2020eliminationgoal.However, theendoftheprogrammerequiresfinancialresourcestosustainthegainsandevensupportsurveysandstudiesthatareneededtodemonstrateelimination.

Aims&Objectives:Theobjectiveof thestudywastoestimatethereturnon investmentofLFeliminationprograminGhanaovertheperiod2001-2017.

Methods:Thisstudyadoptedaneconomicevaluationtoretrospectivelyestimatethereturnoninvestment of LF intervention in the 83 districts that have interrupted transmission in Ghana.Datausedweregatheredfromsecondarysources.

The returns associated with disease prevention was analyzed from two perspectives – directcosts averted and indirect costs averted. Direct costs averted were estimated using directeconomic costs of seeking care (medicines and consultations). Indirect costs averted wereestimatedasthetime(inhours)ofproductivetimelosttoLFclinicalpatientsmultipliedbythe


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daily wage of informal workers. Programme cost was estimated using the WHO-Tool forIntegratedPlanningandCosting(TIPAC)andpublishedstudiesin2002.

Key Findings:The studyestimated that for every US$1invested in LF treatment there is aneconomic return of US$9. The totalprogramme costs for implementation was estimatedatUS$13,832,084.IthasalsobeenestimatedthatindividualsinthebenefitcohortwouldavoidlosingGHS 2,693,821,978.80 (USD63,627,585.74), mainly fromprevented patient medicalexpenses, health system costs savings and potential income loss. Approximately 98% of theprojectedtotaleconomicbenefitwasattributedtothepreventionofreducedproductivityandsubsequentincomeloss.ThetotaldirectcostwasUS$10,992,612.14.

Main Conclusion: This study has provided economic returns data relevant for advocatingcontinuedinvestmentinGhana'sLFprogramme,improvingsustainability.

The effects of lifestyle risk factors and non-communicable diseases on labour force participation in South Africa

NosukoLawana,HumanSciencesResearchCouncilFrederikBooysen,SchoolofEconomicsandBusinessScience,UniversityofWitwatersrandTsegayeAsrat,DepartmentofEconomics,UniversityofFortHare

Background:Theburdenoflifestyleriskfactorsandnon-communicablediseasesinSouthAfricahas been high and rising. The available research on the labour market has highlighted thatchronic diseases are likely to prevent individuals from participating in the labour market.Howeverlittleisknownabouttheimpactoflifestyleriskfactorsandnon-communicablediseasesonlabourforceparticipationindevelopingcountries.Theaimofthisstudywastoexaminetheindirect effects of lifestyle risk factors associated with non-communicable diseases on labourforceparticipationinSouthAfrica.

Methods:DatausedinthisstudywasobtainedfromtheNationalIncomeDynamicsStudy.Thestudyemployedendogenousmultivariateprobitmodelswitharecursivesimultaneousstructureas amethodof analysis. Theeffectsof lifestyle risk factorson labour forceparticipationwereassessedindirectlyusingmarginaleffectsfromsimultaneousequations.

Results: The evidence suggested that non-communicable diseases and associated risk factorshavedetrimental impacton labour forceparticipation.TheanalysiswasalsocarriedouttakingintoaccounttheeffectofgenderdifferencesconsideringthatNCDsmayhaveagreatereffectononegenderthattheother.Theresultsrevealedthattheeffectofstrokeandheartdiseaseswereonly significant for men, while diabetes and high blood pressure were only significant forwomen.Theresultsalsoemphasisedthesignificant indirect impactofobesity,physicalactivityandalcoholconsumptiononlabourforceparticipationthroughNCDs,especiallyformen.

Conclusion:Thispaperprovideevidencethatlifestyleriskfactorsaffectsocietyandeconomynotonlybycausingnon-communicablediseasesbutalsobyreducinglabourforceparticipationrates.The policy implication of this study are gender specific, the results highlight the necessity forinstitutingactivepoliciesdesignedtosupportthelabourforceparticipationofmalesdiagnosedwith stroke and/or heart disease. In addition, policies designed to support labour forceparticipationof femaleswithdiabetesandhighbloodpressureor interventions toprevent theonsetofdiseases itself shouldbeapriority.Thismay includeembarkingmassiveawarenessofhowtopreventandcontrolNCDsonspecificfemalehealthprogrammessuchasmaternalhealthprogrammes. To a greater extent, the findings from the study imply that calls for genderresponsive health approaches which takes into account gender specific needs and prioritiesshouldbepromotedascomparedtoablanketapproach.


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Incidence, socio-economic inequalities and determinants of catastrophic health expenditure for diabetes care in South Africa

ChipoMutyambizi1*,MilenaPavlova2,CharlesHongoro1,WimGroot2,1Population Health, Health Systems and Innovation, Human Sciences Research Council, Pretoria, SouthAfrica2DepartmentofHealthServicesResearch;CAPHRI,MaastrichtUniversityMedicalCentre,FacultyofHealth,MedicineandLifeSciences,MaastrichtUniversity,Maastricht,TheNetherlands

Background:Directoutofpocket(OOP)paymentsforhealthcaremaycausefinancialhardship.For diabetic patients who require frequent visits to health centres, this is of concern as OOPpaymentsmayalsolimitaccesstohealthcare.However,littleisknownabouttheextentofOOPpaymentsandtheincidenceofcatastrophichealthexpenditurefordiabeticpatientsinasettingwith subsidised healthcare in South Africa. This study assesses the incidence, inequalities anddeterminantsofcatastrophichealthexpenditureamongstdiabeticpatientsinSouthAfrica

Methods:Ourstudymakesuseofdatafromauniquecross-sectionalsurveythatwasconductedin2017attwotertiarypublichospitalsinPretoria,SouthAfrica.Weestimatecatastrophichealthexpenditureandimpoverishmenteffectsamongdiabeticpatientsusingdatacollectedfrom396randomlyselectedconsentingpatients.Healthcarecostsrelatedtodiabetescarewereclassifiedas catastrophic if they exceeded a predefined threshold. Erreygers concentration indices (CI)were used to assess socio-economic inequalities in catastrophic expenditure andimpoverishment among diabetic patients. A multivariate logistic regression was applied toidentifythedeterminantsofcatastrophichealthexpenditure.

Results: ThemeanOOP health expenditure for diabetes carewas 53 South African rands perpatients per hospital visit. Depending on the threshold and method used, the incidence ofcatastrophichealthexpenditureduetodiabetescarevariedfrom2%to26%.Catastrophichealthexpenditurewasconcentratedamongstpoordiabeticpatientsas indicatedbythenegativeCIs.Being female, not having children and a household size of 5 people increases the risk ofcatastrophic health expenditure for diabetes care. Being non-African reduced the risk ofcatastrophichealthexpenditure.

Conclusion:Ourstudyshowsthatfinancialprotectionofdiabeticpatientsbypublichospitals islimited. This observation suggests health financing interventions amongst diabetic patientsshouldfurthertargetthepoorandotherdeterminantsofcatastrophichealthexpenditure.ThisisparticularlyimportantfortheachievementofuniversalhealthcoverageinSouthAfrica.

Keywords:diabetes,catastrophic,impoverishment,determinants,SouthAfrica

THE HOUSEHOLD ECONOMIC IMPACT OF RHEUMATIC HEART DISEASE (RHD) IN SOUTH AFRICA

OyelekeO,UniversityofCapeTown,CapeTown,SouthAfrica

Objectives: Due to the paucity of data describing Rheumatic Heart Disease (RHD) economicimpact,weconductedasurveytoinvestigatethehousehold’seconomicconsequencesofRHDinSouthAfrica.

Methods: A cost-of-illness study was undertaken among 100 households affected by RHD inCapeTown.Healthcarecosts,includingdirectandindirectcosts,wereestimatedfromapatient


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(household)perspective.Theprevalenceofcopingstrategieswasalsoassessed, includingbothcostpreventionandcostmanagementstrategies.

EconomiccostswerevaluedinUnitedStatedollar(USD).

Results: One hundred index patients with RHD were included; supplementary socioeconomicdataonhouseholdmembers(n=479)werealsocollected.HealthcarecoststotalledUSD9400(USD91perpatientperyear),comprisingUSD4285indirectcosts(allofwhichweredirectnon-medical costs) andUSD5126 in indirect costs. Total inpatient (52%ofdirect costsand39%ofindirect costs) and outpatient (48% of direct costs and 61% of indirect costs) costs wereestimatedatUSD4200andUSD5200respectively.At10%and40%threshold,4and8percentofhouseholds incurred catastrophic health expenditure. Coping behaviours were frequent andincludedtakingoutloans(17%ofhouseholds),receivinggiftsfromothers(15%).Theestimatedeconomicvalueof thesebehaviourswasestimatedatUSD3000.The total costofRHD to theaverageaffectedhouseholdisvaluedataboutUSD120annually

Conclusions: The economic impact of RHD in South Africa is substantial despite governmenteffortstoprovidesubsidizedhealthcare.Abroaderandmorerobustrangeofsocialpolicies isrequired to mitigate non-medical and indirect costs and reduce distortions in householdeconomicactivity.

NCD’s and economic outcomes in South Africa: a cohort study for the period of 2008-2016 at individual and household level

OdwaMfolozi,DrOAlabaHealthEconomicsUnit,SchoolofPublicHealthandFamilyMedicine,FacultyofHealthSciences,UniversityofCapeTown

The totalnumberofpeople livingwithnon-communicablediseases inSouthAfricacurrently isunknown.AccordingtotheWHO,(2014),non-communicablediseasesareaccountablefor43%ofalldeathsinSouthAfrica.In2011theywereaccountablefor23%ofyearsoflifelostand33%of disability life years, (Ataguba, Akazili,&McIntyre, 2011).Non-communicable diseaseswereunderlyingor accountable for60%of the top ten causesofdeath in SouthAfrica for the year2015,(STATSSA,2017).Governmenttotalexpenditureisalsounknownbutisestimatedatmorethan one billion rands per annum for low to middle income countries such as South Africa,(WHO,2011),(Huffmanetal.,2011).UHCandUpscaledprioritisationatPHClevelisneededasNCD’s accounted for half the global burden of disease but only received 2% of internationaldonationscomparedtoHIVthataccountedfor4%oftheglobalburdenofdiseasereceiving29%ofinternationaldonationgrants,(Allen,2017).

NCD’s negatively impact the labour market by decreasing labour productivity, increasingemployeeturnoverandearlyretractionfromthelabourmarket.Thisfuturedecreasesindividualincome and household income especially for the urban poor who carry the heaviest non-communicablediseaseburden in SouthAfrica. This further contributes to themedical povertytrapandworsensincomeinequalityinSouthAfrica.

Using panel data from the national income dynamics study in South Africa, this paperinvestigates the association between non-communicable diseases and labour marketparticipationand theeffect ithasonhousehold income.Weexamine theseassociationsusingstatistical regressionmodels for NCD exposed households and non NCD exposed households,comparingthetwofordifferences.

We hypothesis thatNCD’s decrease household income and labour force participation throughdecreasing individual and household productivity and by increasing dependency both for the


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individual and the household. Therefore as recommended by the WHO; individual specificinterventionswillbemoreeffectivethanpopulationbased interventionstoalleviatetherippleeffects of the non-communicable disease burden on the South African economy (NationalDepartmentofHealth,2013).

References;

Allen, L. N. (2017). Financing national non-communicable disease responses. Global HealthAction,10(1),1326687.https://doi.org/10.1080/16549716.2017.1326687

Ataguba,J.E.,Akazili,J.,&McIntyre,D.(2011).Socioeconomic-relatedhealthinequalityinSouthAfrica: evidence from General Household Surveys. International Journal for Equity in Health,10(1),48.https://doi.org/10.1186/1475-9276-10-48

Huffman, M. D., Rao, K. D., Pichon-Riviere, A., Zhao, D., Harikrishnan, S., Ramaiya, K., …Prabhakaran,D. (2011).Across-sectional studyof themicroeconomic impactofcardiovasculardisease hospitalization in four low- and middle-income countries. PLoS ONE.https://doi.org/10.1371/journal.pone.0020821

National Department of Health. (2013). Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013-2017. Department of Health. Retrieved fromhttp://www.hsrc.ac.za/uploads/pageContent/3893/NCDs STRAT PLAN CONTENT 8 aprilproof.pdf

Parallel Session 7-3 New trends and debates in international health financing

Evaluation of Performance of the African Union Support to Ebola Outbreak in West Africa (ASEOWA) Mission in Controlling Ebola Virus Disease (EVD) and Restoring Health Services in Guinea, Liberia and Sierra Leone.

Ifeanyi Nsofor,ChikweIhekweazu,AdaEzeokoli:ABUJAEpiAFRIC

Background: In September 2014, the African Union announced the deployment of healthworkersandotherspecialiststotackletheEbolaVirusDiseaseoutbreakinWestAfricaunderitsoperation “African Union Support to Ebola Outbreak in West Africa” (ASEOWA). The EVDoutbreak responsewas complicated,with lotsofmovingparts involving thousandsofnationalandinternationalstaff.

Aims and Objectives: The aim was to evaluate the performance of ASEOWA mission insupportingthecontroloftheEbolaoutbreakandrestoringhealthservicesinGuinea,LiberiaandSierraLeoneandtodocumentareasofnewlearning.Itwasimportanttounderstandhowbesttodeployhealthcareworkersonthisscaleinresponsetoapublichealthemergency,toinformdecisions on future missions. The outputs could enable the African Union to identify itsstrengths,respondtoitsweaknessesandusethelessonslearnttocontinuouslyimprovethewayitservesandrelatestoitshostcountries.

Methods:Weusedbothqualitativeandquantitativemethodstoaddresstheprojectobjectives.Purposivesamplingwasemployedinselecting“keyinformantinterview(KII)”and“focusgroup


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discussion(FGD)”participants.Anonlinequestionnairewasfield-testedandadministeredtoallthevolunteers

Key Findings: 80%of participantswereunder 40 years,mostly early careerprofessionals, andmostdescribedtheirexperienceaseitherverygoodorexcellent.About60%hadjobstogobackto in their home countries. Case management, capacity building and surveillance were areaswhereASEOWAaddedparticular value. In infectionprevention and controlASEOWAprovidedexpertise and human resources that made the successful “Ring Approach” possible. Officialsfrom host countries appreciated the insistence of ASEOWA on harmonisation of responseactivitiesandasASEOWAvolunteerswerealldeployedforlongperiods,exceedingthelengthofstay of colleagues from other partner organisations, they were well recognised and oftenbecamethosewiththelongestinstitutionalmemory.

MainConclusions:OurevaluationindicatedthattheASEOWAmissionplayedauniquevitalroleinoutbreakcontrolwithexpertisefromalargenumberofAfricanprofessionalsdeployed,whoseabilitytoblendinwasrecognised.Thecommonestcriticismofthemissionfromthevolunteers&otherstakeholdersrelatedmostlytothemanagementofthemission,arrangementsforlogistics,transport,processesandpayments.

UHC through PHC: Piloting Preferred Primary Care Provider Networks in Ghana

*KokuAwoonor,**ElizabethHammah,***ChrisAtim*GhanaHealthService,**UniversityResearchCo.,LLC,***ResultsforDevelopment

Background: Provider mapping study conducted in 2014 indicated a wide variability in thecapacity (often inadequate) of health providers to deliver the package of services defined forPHC.FormationofprovidernetworksisoneinnovativeapproachtocatalyzeindividualproviderswithvariablecapacitytoformrobustprimaryhealthorganizationsthatcandeliverthecompletepackageofPHCservices.InSeptember2017,theMinistryofHealth,incollaborationwithGhanaHealth Service andNational Health Insurance Authoritywith support fromUSAID Systems forHealthandR4D, launchedan18-monthpilot in2districts intheVoltaRegionofGhanatotesthownetworkarrangementscanimpactthedeliveryofhigh-qualityPHC.

Aimsandobjectives:Testnetworkmodelsandreferralarrangements thatenableCommunity-Based Health Planning & Services (CHPS) to thrive and make policy and operationalrecommendations.

Method used: “Hub-and-Spokemodel” to form 10 networks. In this model, a group of CHPSclinics (spokes) are connected to onehealth centre (hub) to receive technical andoperationalsupport including access to higher cadre providers, laboratory services, mentoring andsupervision. Network facilities received physical upgrades (infrastructure and equipment) andtraininginnetworkoperationsandmanagement.

Keyfindings:Preliminaryobservationsshowpositiveresults:

- AnetworkcomprisedofahealthcentrewithsatelliteCHPScompoundscanworktogetherandshareresourcesasaneffectiveandefficientteamunit.Networkmembersshareknowledge,expertiseandlogisticalresources.

- NetworksundertakejointplanningtoaddresscommonproblemssuchasreviewinghealthInsuranceclaimstominimizethenumberofrejections.


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- Anearlyandconsistentobservationisastrongerreferralsystem,includingestablishedprocessesanddocumentationforreferralsthatleadstobetter-informedprovidersandpatientsonreferralcases.

- Communitymobilisationandsupportisvariable,butthepresenceofhighercadrestaff(PAormidwife)duringcommunityoutreachreportedlyboostscommunityacceptanceandconfidenceintheCommunityHealthOfficers(CHOs).

Mainconclusion:Formationandstrengtheningofnetworksattheprimarycarelevelcouldbeakeystrategytowardsachievinguniversalhealthcare.Asdemonstratedbytheearlyphasesofthepilot, thenetworkscouldplayakeyrole inbuilding individualprovidercapacity, strengtheningreferralsystems,andenhancingequitableaccesstokeyPHCservices.

An analysis of donor financing of human resources for health activities and health worker migration in Sub-Saharan African countries

AngelaMicah,InstituteforHealthMetricsandEvaluation/UniversityofWashington Background:In2016,sub-SaharanAfricahad21%oftheglobalburdenofdisease,yetonly5%oftheglobalhealthworkforce.Oneofthedriversoftheglobalhealthworkforceimbalanceisthemigrationofhealthworkers.Recognizingthechallengesassociatedwiththeethicalrecruitmentof health professionals globally, the WHO Global Code of Practice on the InternationalRecruitment of Health Personnel was instituted in 2010. The code encourages high-incomecountries toprovide financialand technicalassistance to low-incomecountries tomitigate theimpactofhealthpersonnelemigration.Whereasthe issueofemigrationofhealthworkersandits associated impact on the health system has beenwell described in the literature, there islimited evidence on the issue of emigration and the transfer of development assistance forhealthresources.

Aimsandobjectives:Theobjectiveofthisstudyistoexaminetherelationshipbetweentheflowofdevelopmentassistanceforhumanresourcesforhealth(DAHRH)andtheemigrationofhealthworkers.

Methods: The study uses data from the Institute for Health Metrics and Evaluation’s 2017DevelopmentAssistanceforHealthdatabase.Thisdatatracksdevelopmentassistanceforhealthfrom1990through2017.DAHRHestimatesislinkedtodataonphysicianmigrationtotheUnitedStates, United Kingdom, Canada and Australia. We use regression analysis to assess theassociationbetweenthechangeinthenumberofforeigntrainedphysicianspracticinginthesefour high-income countries and change in the amount of DAHRH received by sub-Saharancountries.

Key findings: Preliminary results suggest there is a positive association between the flow ofdevelopmentassistanceforhumanresourcesforhealthandtheemigrationofhealthworkers.A10% increase in development assistance for human resources for health is associated with a2.4% increase in thenumberof physiciansmigratingoutof the country (0.24–95%CI 0.14–0.35). Additional analysis will explore alternative models to examine the robustness of thefinding.

Conclusion:Healthworkeremigrationpresentssignificantchallengesforhealthsystemsinsub-Saharan Africa. The preliminary results suggest that other interventions besides additionalinvestmentintrainingandotherhumanresourceactivitiesmaybenecessarytostemtheflowofhealthworkersoutofsub-SaharanAfrica.


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Towards achieving the health-related SDGs: the role of unconditional cash transfers in Africa

JacobNovignon,KwameNkrumahUniversityofScienceandTechnology,Kumasi-Ghana

Improvinghealthcareaccessandoutcomescontinuetodominateglobaldevelopmentagenda.IntheSDGsvarioustargetshavebeensettoensuresignificantprogressbytheyear2030.Thisisparticularlyrelevant inAfricawhereseveralcountries lagbehind inhealthoutcomes. Inrecentyearsmanygovernmentsintheregionhaveturnedtocashtransferprogrammeswiththeaimofimprovingpoverty,educationandhealthoutcomes.However,whileunconditionalcashtransfershave demonstrated widespread, positive impacts on consumption, food security, productiveactivities,andschooling,theevidencetodateonhealthseekingbehaviorsandmorbidityinthecontextofunconditionalcashtransfersinAfricaismorelimited.

Against this backdrop,we investigate the impact of unconditional cash transfers onmorbidityandhealthseekingbehaviorusingdatafromexperimentalandquasi-experimentalstudydesignsinKenya,Malawi,ZambiaandZimbabwe.ProgrammeimpactswereestimatedusingDifference-in-Differences(DiD)estimationtechniquewithlongitudinaldata.

The results indicate favourableprogramme impactsonselectedhealth indicators (incidenceofillness)andhealthseekingbehaviours.Therewasalsoprotectiveimpactonhealthexpenditure.The findings were, however not consistent across countries. We also found that, in somecountries, programme impact worked through supply side factors, including improved healthcarequality.

The findings suggest that while unconditional cash transfers could improve health and healthseeking, simultaneous improvements in supply side infrastructure, or facilitation of linkagesbetweenexisting facilitiesand cash transferhouseholds, is likelyneeded formorewidespreadimpactsonmorbidityandhealthseekingtomaterialize.

Keywords:Morbidity, health-seeking, health care utilization, Cash transfers, social protection,Africa

The role of NGOs in health systems strengthening to achieve UHC – Botswana’s experience with Global Fund to Fight AIDS, Tuberculosis and Malaria

DintleMolosiwa,GaboroneBoitekaneloCollege

Background: Non-governmental Organizations (NGOs) are critical actors and State partners,especiallyforhealthcareservicedeliveryatthecommunityplatformtoadvanceuniversalhealthcoverage (UHC)and toachievesustainabledevelopmentgoals.However,NGOsarechallengedby issues of capacity and sustainability, diminishing State confidence to form strategicpartnershipswiththem.TobuildandsustainstrongerhealthsystemsforUHC,meaningfulandeffective engagement of NGOs is needed. Situated in Botswana’s context of commitment toachievingUHCandtakingonahighershareforHIVfunding,thisstudyexploredtheinstitutionalmanagementoftheGlobalFundtofightAIDS,TudercolosisandMalaria.

Methods: In-depth interviews (16),withpolicymakers; allGFATMprincipal and sub-recipients(PR&SR);CountryCoordinatingMechanismofficers(CCM);andNGOsdirectors/employeeswereconducted in October – December, 2017. Process-tracing and observationswere also used toexplore governance and accountability across GFATM stakeholders. All interviews were taperecorded,transcribed,codedandanalysedthematically.


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Results: There are two PRs for the currentGFATM,Ministry of Health andWellness (MOHW)whichdoesnothaveSRandtheAfricanComprehensiveHIV/AIDSPartnership(ACHAP)whichhasfourSRs(beingNGOs).The‘bigbrother’relationshipoftheStateoverNGOsposesasignificantchallenge. State actors view NGOs as a threat to good governance and leadership. Issues ofqualityofcare;geographicscopeandperceptionsofNGOs’capacitytodeliverareimpedingtheessential roleofNGOs.TheCCMasanoversightmechanismhascreatedaneffectiveplatformfor meaningful forms of accountability to communities; also creating shared vision and aplatformthroughwhichNGOsareabletocoordinatetheirworkandcreatesynergies.However,the CCM has not been effective (forthcoming) in holding the State (as PR) accountable forperformingpoorlyunderthecurrentGFATMgrant–theimpactofwhichis‘crowdingout’donorfundingduetoinefficiencytoutilizeavailedfunds.

Conclusion:NGOsinBotswanaremainapoorlyusedactorforstrengtheninghealthsystemsandadvancing UHC, including reaching key populations which remain marginalised. The GFTAMrepresentanopportunityforcreatingavibrantcivilsocietywhoselocalactivitieswillnotbeseenasbeingledcovertlybytheState.

Parallel Session 7-4 Human Resources for Health - country experiences

Cost effectiveness analysis of fully time paid community health worker in three rural districts – Tanzania: Rufiji, Kilombero and Ulanga

KassimuTani,IfakaraHealthInstitute Background:Communityhealthworkers (CHW)havebeen inplace foranumberofyears.TheWHOadvocates theuseofCHWtoexpandhealth servicescoverage,asoneof themethod totackle health workers shortagesmostly in developing countries health systems.Many studieshavedepicted the importanceCHW in improvingcommunityhealthespecially inmaternalandchild health but few looked on cost effectiveness,mostlywith full time paid CHWworking inhealthsystems.

Objective:ToassessthecosteffectivenessofdeployingfullytimepaidCHWwithmultitasks inruralhealthsystemofTanzania.

Method:Thecostdetailedwasprospectively collected throughout the implementationof theprogram. Life years gained was estimated based on the number of under five death aviatedresulted from health services coverage after introducing full time CHWs to the villages.Incremental cost effectiveness of deploying a paid CHW was estimated from the providerperspective.Dataoncostoftraining,deploymentandrunningwerecollectedfromJuly2010toJune 2015. Gross domestic product was used as the reference for the willingness-to-paythresholdvalue.

Result:Theestimated incremental costeffective ratio (ICER)per lifeyeargainwas20.22USD.And the country gross domestic product (GDP) per person for year 2013 is 694.7. With thisscenario,thattheICERis lessthantheGDP,fortheunderfivechildmortalityrateof151.4for


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thecontroland144.8fortheinterventionareaper1000lifebirth,thefulltimedeployedCHWsintervention considered cost effective. The result was most sensitive to uncertainty in theestimateoflifeyeargained.

Conclusion: The full time paid CHWs appeared to be cost effective when serving ruralcommunity especially those with insufficient health professions. The use of these CHWs toexpandhealth coverage,mostly in rural andunder saved communities facilitates theavailablehealthfacilityworkerstoconcentratefullyathealthfacilityandjustsetfewhourstosuperviseCHWworkingwithintheirfacilitycatchmentarea.

Pushing back Universal Health Coverage: Causes and consequences of absenteeism of health workers at the PHC level in Nigeria

PrinceAgwu1,5,ObinnaOnwujekwe2,5,OdiiAloysius3,5,OrjiakorTochukwu4,5,PamelaOgbozor5DepartmentofSocialWork,UniversityofNigeria,Nsukka1

DepartmentofHealthAdministrationandManagement,UniversityofNigeria,Enugu,Nigeria2DepartmentofSociology,UniversityofNigeria,Nsukka3

DepartmentofPsychology,UniversityofNigeria,Nsukka5

Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine,UniversityofNigeria,Enugu-Campus,Enugu,Nigeria4,5

Background: Primary healthcare centers (PHCs) are the closest source of formal healthcareservices to healthcare consumers, especially for rural dwellers. PHCs arewidely spread acrossthe 774 Local Government Areas of Nigeria, and statutorily within the direct control of localgovernment areas. However, there is inefficiency of health workers at the PHC level, withabsenteeismamajorcauseoftheproblem.Hence,itisimportanttodeeplyexaminetheissueofabsenteeismofhealthworkersacrossPHCsinNigeria.

AimsandObjectives:Thestudyassessedthecausesandconsequencesofabsenteeismamongstfrontline health workers at the PHC level on health outcomes, and also solutions. Otherobjectives were to examine the influence of gender, political economy, social events, maritalresponsibilities, distance, work equipment, and remuneration on absenteeism. The study alsoinvestigatedthepossibleeffectivenessofdifferent interventionsalreadyinplaceatthesePHCstocurbabsenteeismandtheirlikelyeffectsonhealthworkers’presenceandefficiencyatwork.

Methodology: The publication by Belita et al (2013) on developing typology for absenteeismhelpedprovideaconceptualframeworkwereweconsideredcategoriesofabsenteeismthatarecorruption laden from those that are not. The study relied on qualitative methods of datacollectionandanalysis.ThepopulationwasconcentratedintheSouth-EastofNigeria.PurposivesamplingwasusedtoselectthePHCfacilitiesandrespondents.Datawascollectedusing20in-depth interviews (IDIs)with frontlinehealthworkersandhealthsectoradministrators.While6FocusGroupDiscussion(FGD)wasadoptedtoelicitresponsesfrompatients

FindingsandConclusion:AbsenteeismwascommonamongsthealthworkersinPHCsinNigeria.Influence of gender, political economy, marital responsibilities, work welfare includingremunerationand security, aswell aspoorlyequipped facilitieswere frequentlymentionedascausesofhealthworkers’absenteeism.Existinginterventionswerefoundnottobeadequatetocheck absenteeism. Political influences should be addressed in order for sanctions onabsenteeism towork.Asall thesewhenaddressedwouldamount to speedy realizationof the2030UniversalHealthCoverage.


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A systematic review: interventions for improving the retention of physicians working in rural areas to strengthen Primary Health Care.

DrAtsushiSAMURA,WorldHealthOrganizationCountryOffice,MauritiusDrFaisalSHAIKH,DrLaurentMUSANGO Background: The imbalance of health workforce within a country is regarded as a majorchallengeofimprovinghealthequityandstrengtheningPrimaryHealthCare(PHC).Forinstance,ahalfof globalpopulation live in rural communitiesandare servedbyonly24%ofphysiciansworldwide.Alotofgovernmentshaveimplementedinterventionsinfourcategories(education,regulation, financing and professional supports) in accordance with the WHO Global PolicyRecommendations. However, no country has yet achieved the equal distribution of healthworkforce.

Objectives:Toestablishtheexistingevidenceaboutinterventionsforimprovingtheretentionofphysiciansservingruralcommunities.

Methods:Cochrane’sEPOCapproachwasemployedtoconductthissystematicreview.

[Searchmethods] I searchedMEDLINE,Embase,CochraneCentralRegisterofControlledTrials,GlobalHealthandWebofScience.WealsosearchedthereferencelistsofallincludedliteratureandconductedacitationsearchinWebofScience.

[Selectioncriteria]Randomisedcontrolled trials,non-randomised trials; controlledbefore-afterstudies,interruptedtimeseries(ITS)studiesandcohortstudiesinvestigatingtheimpactsofanyinterventionsamongstfourcategoriesonruralretentionofphysicians.

[Datacollectionandanalysis]Onereviewauthor independentlyscreenedallpotentiallyeligiblerecords, extracted data and assessed risk of bias for each of the included article. Narrativesynthesiswasconductedduetosubstantialheterogeneityacrosstheincludedstudies.

Key findings:After 1646 recordswere screened, 10 studieswere identified for data synthesis(four from the US; two from Japan; and one from Canada, Thailand and Turkey). Two cohortstudies involving 2784 physicians compared rural deployment not linked to education withcontrol.Fourcohortstudiescomprising7548physicianscomparedmandatoryservice linkedtofundededucationwithcontrol.FourITSstudiesinvolving274130and337864physiciansatpre-andpost-interventionperiodcomparedequityofgeographicaldistributionofphysicianswithinthecountrybetweenbeforeandaftertheimplementationofnationwidepolicies.Wejudgedthecertaintyoftheevidenceforretentionanddistributionwasallverylowmainlyduetohighriskofbias,lowgeneralisabilityandimprecisionoftheeffect.

Conclusions: There is limited certainty of the evidence due to high risk of bias. Governmentsshould collect comprehensive data (including potential confounders) where researchers canconduct well-designed studies. As for identified interventions, Taiwan’s lesson is noteworthybecause it showed that implementation of national health insurance triggered physicians torelocatetoruralareas.

Key words: health workforce, physicians, retention, rural health, universal health coverage,systematicreview

Investment in health human resources and economic growth in Ivory Coast

AugusteK.KOUAKOU(1);RomualdGUEDE(1);AppolinaireYapi(2)(1)UniversityofJeanLorougnonGuede(Daloa,IvoryCoast) (2)NationalInstituteofPublicHealth-Abidjan(IvoryCoast)


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TheworkofHigh-LevelCommissionoftheUnitedNationsonEmploymentandEconomicGrowthsince2016hasplacedattheheartoftheinternationalagenda,thebenefitsofinvestinginhealthhumanresources(HHR)forboththehealthofpopulationandtheeconomicgainforsociety.Thispaperaimstodeterminetheimpactsofinvestmentinhealthworkersandeconomicgrowth.TheSocial Accounting Matrix approach highlights the mechanisms for transmitting this effect onemployment,theproductivesectorandGDP.

Basedonthemultipliersofthe2013socialaccountingmatrix,thisresearchanalysesthenatureof sectoral linkages and assesses the impact of HHR expenditures on the Ivorian productivestructure and institutional units. The methodology used is one of an Esther-type socialaccountingmatrixinanopeneconomy.

Results:Thestudyshowsthatthemining(AMININ),construction(ACONST)andhealth(ASANTE)sectorsarekeysectorsofIvorianeconomybecauseindicators𝐵!! >1et𝐹!! > 1.

" The costs of personnel (1.1) and health investments (1.1) have priority over currenthealthexpenditures(0.9).

" Anincreaseinhealthpersonnelcostsleadsto:o Aproductioneffects

→ Anincreaseof0.01%inagriculture,0.12%inmining,etc.,i.e.anincrease

inGDPof0.56%;

→ Areturneffectof0.14%;

o Anincomeeffects

→ Anincreaseinaveragehouseholdincomeof0.14%;

→ Anincreaseincorporateincomeof0.17%;

→ AnincreaseinincomeintheRestoftheWorldof0.29%;

o Anemploymenteffects

→ According to gender, the policy leads to an improvement in female

(FEMLAB)employmentof0.27%andformale(MALELAB)of0.37%.

Conclusion: Theobjectiveof the studywas todetermine the contributionofhealthpersonnelcoststoeconomicgrowthinIvoryCoast.Indeed,a1%increaseinhumanresourcesexpenditureon health leads to 0.56% increase in national production (GDP), 0.14% increase in averagehouseholdincomeand0.32%increaseinemployment.

The study therefore shows that the importance of increasing investment in HHR has a

positive impact on wealth creation and job creation.

Motivation of community-based health agents in Burkina Faso: sustainable strategies implemented, and learnt lessons

AwaOuedraogo1,ErmelJohnson21MinistryofHealth,BurkinaFaso2WestAfricanHealthOrganization Background information: Like countries that have adopted primary health care, Burkina Fasousescommunityactorstoprovidehealthservices.Amongtheseactorsarethetwocommunity-basedhealthagents (CBHAs)pervillage.Astudyconducted in2012showed lowmotivationof


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CBHAs,andadesireforfinancialtreatmentasthefirsttypeofmotivation(80.2%).AnewprofilehasbeendefinedandBurkinaFasohascommitteditselftoamonthlymotivationoftheCBHAs.

Objective:ThepurposeofthisstudywastodescribethesustainablemotivationalstrategiesoftheCBHAsdevelopedandthelessonslearned.

Methodologies: Working meetings based on the results of the situational analysis wereorganized. They involved representatives of the Ministry of Health, local authorities,management committees, non-governmental organizations and associations, community ofleaders,CBHAs,technicalandfinancialpartners.Thefinaldocumentwasamendedandvalidatedat a cabinetmeeting of theMinistry of Health, adopted by the Council ofMinisters and thendistributed.

Results:Threemotivationalstrategieshavebeenselected:

• materialincentives:identificationvests,bags,megaphones,…;• intangibleincentives:officialinstallation,certificatesoftraining,honoraryawards,etc;• financial motivation: profits from the sale of medicines, training fees, monthly bonus

from the State budget with the contribution of partners; paid through electronicportfolioservices.

From the implementation of these motivational strategies, several lessons have been learnt.Indeed,themotivationmechanismmustbedefinedthroughaparticipatory,consensualprocessinvolvingallstakeholdersandtheroleofeachgovernmentalandnon-governmentalactormustbe specified. The CBHAmappingmust be established before the process begins and regularlyupdated. Remunerationmust be secured by a payment plan. A systemmust be identified toensurethatactivitiesareeffectivelyimplementedbeforepaymentismade.Themobilepaymentsystemmustbeavailablenationally.

Conclusion: The motivation of CBHAs is a prerequisite for community health care. Amultisectoralvisionofahealthinterventioninaparticipatory,consensualandclearstakeholderengagementprocessisindispensableforitssuccessandespeciallyforitssustainability.

Parallel Session 7-5 Preferences and willingness to pay Assessment of the acceptability of Community Based Health Insurance as a health financing mechanism and maximum willingness to pay amongst urban slum dwellers in Abuja, Nigeria. 1Ewelike,UchennaEugenes;2Onwujekwe,Obinna;3Okoronkwo,Ijeoma;4Obikeze,Eric

Department of Health Administration and Management, Faculty of Health Sciences and Technology,UniversityofNigeria,EnuguCampus

Introduction: Lack of financial risk protection especially for households within the informalsector has been the bane of the Nigerian Health System. Many of the citizens pay for theirhealthcare needs through the regressive out-of-pocket payment method. Community BasedHealthInsuranceisoneofthenon-mandatorywaysofraisingrevenuetofinancehealth.Beinganon-mandatorymethod,it’simportanttoscientificallyelicitacceptabilityandstatedpreferencesamongsthouseholds.Willingnesstopaywhichisacontingentvaluationmethodwasusedinthisstudy to elicit maximum amount urban slum dwellers in Abuja were willing to pay and the


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acceptabilityofCBHI.ThestudywasaquantitativestudyinvolvingfiveurbanslumsinAbuja.Thequantitativewasa cross sectionaldescriptive studyusingamulti-stage systematic sampling todeterminepricing,willingnessandacceptabilitybyapplicationofwell-structuredquestionnairesasan interview tool.Quantitativedatawasanalyzedusingdescriptive statistics, statistical testandpresented inchartsand tables.Thestudyrevealedveryhighacceptability forCBHI81.4%,willingnesstoenroll forself (78.2%)and(74.8%)forotherhouseholdmembers.ThestudyalsoshowedthatatpremiumN500.00only,59%oftheurbanslumdwellerswerewillingtopayforCBHI while 72.2%were willing to pay a premium of N400. Themaximum amount they werewilling to paywas N613.77, N554.65 and N456.65 for self, householdmembers and altruisticrespectively. Urban slum dwellers in Abuja accepted CBHI and are willing to utilize the socialsolidarity inherent in community financing and contribute for their healthcare needs throughCBHI.TheseslumdwellerscanwillinglycontributeN500perpersonpermonthusingthemedianpriceof this study. It is recommended thatowning to thehighacceptabilityandwillingness topay findingsof this study, theFederalCapital TerritoryHealthandHumanServices SecretariatshouldimmediatelycommencetheprocessofactivatingCBHIpoolsacrosstheslumsinAbujatoeasetheiraccesstohealthcare.

KeyWords:Acceptability,Willingnesstopay,(WTP),CommunityBasedHealthInsurance(CBHI),UrbanSlumsandAbuja.

Willingness to pay for health insurance among commercial motorcyclists in Nakawa division, Kampala capital city authority, Uganda

JudithHopeKiconco,ProfRobertBasaza,ElizabethPatienceKyasiimire

Background & Objectives: Willingness to pay(WTP) is the maximum amount an individualiswillingtosacrificetoprocureagoodoravoidsomethingundesirable.Oneofthecitizengroupsthatrequirehealthinsurancearethecommercialmotorcyclists,giventhattheyareconsideredtobe low incomeearnersandyet theyconcurrently facehigh risksofgetting involved in roadtrafficaccidents.

Methods: This study used a descriptive cross sectional research design. NakawaDivisionwaspurposivelysampled.TosampleoutthestudyparishesintheDivision,simplerandomsamplingwasused.GiventhatBodaBodastagesdonothavespecificstagepointsmappedoutorzonedoutineachoftheparishesintheDivision,theyweresampledconvenientlygiventhattherewerebetween15-10ridersateachsampledstage.Simplerandomsamplingwasusedtosampletherespondents.

Results:Thelevelofwillingnesstopayforcommercialmotorcyclists’healthinsurancewasfoundtobe70%,basingontheproportionofcyclistswhowerereallywillingtopayanamountgreaterthan or equal to UGX 70,000, the current average premium for all available commercialmotorcyclistshealthinsuranceschemesinUganda.

Conclusion: Willingness to pay for health insurance is fairly high among commercialmotorcyclistsinNakawaDivision;however.

Recommendation:Government to consider rolling out and/or expanding themotorcycle loanscheme inwhich riders can personally own amotorcycle as a loan and clear the payments ininstallments.Thiscreatesmoreriderswhoareself-employedandhencemorewillingtopayforinsurance.


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Willingness to pay for contributory health insurance: Findings from an exploratory study in the state of Kaduna, Nigeria

YewandeOgundeji,KelechiOhiri,BabatundeAkomolafe:Abuja,HealthStrategyandDeliveryFoundation

Many states in Nigeria are towing the path of the global and national drive of designing andimplementingsocialhealthinsuranceschemes(SHIS).Thisstudyassessesthewillingness-to-pay(WTP) forSHIS inNigeria toprovide informationabout the relationshipbetween thepremiumthatisrequiredtocoverthecostsoftheschemeandexpectedinsuranceenrollmentlevels.

Thestudytookplacein6localgovernmentareasinKadunastate,North-westNigeria.Datawerecollected from a household survey using a three-stage cluster sampling approach, with eachhouseholdhavingthesameprobabilityofbeingselected.Interviewswereconductedwith4000individualsin1020households.Contingentvaluationwasusedtoelicitthewillingtopay(WTP)for thehouseholdusing thebiddinggametechnique.The relationshipbetweensocioeconomicstatusandWTPwasalsoexaminedusinglogisticregressionmodels.

About82%ofthehouseholdheadswerewillingtopayinsurancepremiumsfortheirhouseholds,whichcametoanaverageof513Naira (1.68USD)permonthperperson.Theaverageamountindividualswerewillingtopaywaslowerinruralareas(611Naira)comparedtourbanareas(463Naira). These results were influenced by household size, level of education, occupation andhousehold income. Inaddition,only65%of thehouseholdshad theability topay theaveragepremium.

Socioeconomicfactorsinfluenceindividuals’WTPforcontributoryhealthinsuranceschemes.Itisimportant to createawareness about thebenefitsof the insurance scheme,especially in ruralareas,andinboththeformalandinformalsectorsinNigeria.WTPinformationcanalsobeusedfor setting insurance premium. However, it is important to consider differences between theWTPand thecostofbenefitspackage tobeoffered,as thepremiumamountmayneed tobesubsidizedwithpublicfinancing.

Caregivers’ willingness to accept and pay for HIV and Sickle Cell Screening at Immunization Centers in Nigeria

MadukaDonatusUghasoro1,SomkeneChinweOkpala2,AlexandraChinenyeNwosu31DepartmentofPaediatrics,UniversityofNigeriaEnuguCampus,Enugu,Nigeria.2DepartmentofPaediatrics,UniversityofNigeriaTeachingHospital,Ituku/Ozalla,Enugu,Nigeria3DepartmentofPaediatrics,FederalMedicalCentre,Umuahia,AbiaState,Nigeria

Background:EarlydetectionofHIVandsicklecelldiseaseswillenabletimelycareandtreatment.However, many apparently health children remain unaware of their HIV and Heamoglobingenotype status. Their status are only known when they developed symptoms and visithealthcare facilities. This is a challenge in places where there is poor access to health care.Fortunately,accesstoimmunizationatthewell-childclinicshasremainhighinNigeria.Thustheneed toevaluate thewillingness to testandpay forHIVandHeamoglobingenotypescreeningamongmothersthatpresentatthewell-childclinic.

Methods: A cross-sectional study was conducted in two states. Data were collected byintervieweradministeredquestionnaire.TheLikertscalewasusedtodeterminetheirwillingness,whilethecontingentevaluationmethodwasusedtodeterminetheamounttherewerewillingto pay. The amount calculated in Nigerian naira and converted to United States Dollars using2017exchangerateof360nairaforoneUS$.


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Results:Ofthe197mothersthatparticipatedinthesurvey,142(72.1%)and121(61.5%)knewtheirHIVandHeamoglobingenotyperespectively.ThosewillingtoscreenforHIVandSicklecellwere 191 (97%) and 188 (95.4%) respectively. Majority 159 (83.1%) and 160 (85.1%) wereextremelywilling for their children to be screened forHIV and Sickle cell respectively. Amongthosewhoexpressedwillingness tobe screened, themedianamount theywerewilling topaywas 500 naira (US$1.38) for HIV and Sickle cell each. Among the participants 76 (38.2%)expressedconcernthatinclusionofHIVscreeninginimmunizationvisitsmaydiscouragemothersfrombringingtheirchildrenforimmunizationatsuchfacilities.

Conclusion: The acceptance of parents to screen their children for HIV and Heamoglobingenotypewashigh,evenatiftheyhavetopayforit.Thusintegrationofsuchprogrammealongwithimmunizationisfeasiblebutshouldremainvoluntaryandonopt-outbases.

Patients’ willingness to pay for the treatment of tuberculosis in Nigeria: exploring own use and altruism.

OgbonniaG.Ochonma,ObinnaE.OnwujekweDepartment of Health Administration and Management, Faculty of Health Sciences and Technology,CollegeofMedicine,EnuguCampusUniversityofNigeria

Background Aim and Objective: Although, current treatment services for Tuberculosis (TB) inNigeriaareprovidedfreeofchargeinpublicfacilities,thebenefits(value)thatpatientsattachtosuch service is not known. In addition, theprices that couldbe charged for treatment in casegovernment and its partners withdraw from the provision of free services or inclusion of theservicesinhealthinsuranceplansarenotknown.Hence,thereisaneedtoelicitthemaximumamountsthatpatientsarewillingtopayforTBtreatmentservices,bothforthemselvesandfortheverypoorpatients thatmaynotbeable topay if someuser feesare introduced (altruisticwillingnesstopay).

Methods:Apretested interviewer-administeredquestionnairewasusedtoelicit themaximumwillingness to pay (WTP) for TB treatment services from TB patients in a tertiary hospital insoutheastNigeria.WTPwaselicitedusingthebiddinggamequestionformatafterascenariowaspresented to the respondents. Data was analysed using tabulations. Tobit regression modelswereusedtoexaminethevalidityoftheelicitedWTPforownuseandaltruisticWTP.

Results:Theresultsshowthat thoseaged30yearsandbelowconstitutedmorethantwo-fifth(43.2%) of the respondents. More than half of the respondents (52.8%) were not employed.Eighty percent 100 (80.0%) of the respondents were willing to pay for their own use of TBtreatment services while 78(62.4%) of the respondents were willing to make altruisticcontributions so that the very poor could benefit from the TB services. A Tobit regressionanalysis of maximum WTP for TB for own use shows that respondents were willing to paymaximum amounts at different statistically significant levels. The results equally show thataltruistic WTP was positively and statistically significantly related to the employment status,distancefromUNTHandglobalseriousnessofTB.Conclusions:Mostpatientspositivelyvaluedthe provision of free TB services and were willing to pay for TB treatment for own use. Thebetter-offoneswerealsowillingtomakealtruisticcontributions.FreeprovisionofTBtreatmentservices is potentially worthwhile, but there is potential scope for continuation of universalprovision of TB treatment services, even if the government and donors scale down theirfinancingoftheservices.


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Determining preferences for different Benefit Packages and Willingness to Pay for Community-Based Health Insurance among the urban slum dwellers in Abuja, Nigeria 1Ewelike,UchennaEugenes;2Onwujekwe,Obinna;3Okoronkwo,Ijeoma;4Obikeze,Eric

Department of Health Administration and Management, Faculty of Health Sciences and Technology.UniversityofNigeria,EnuguCampus

Introduction: Lack of financial risk protection especially for households within the informalsector has been the bane of the Nigerian health system. Many of the citizens pay for theirhealthcare needs through the regressive out-of-pocket payment method. Being a non-mandatory method, it’s important to scientifically elicit the stated preferences amongsthouseholds.Willingnesstopaywhichasacontingentvaluationmethodwasusedinthisstudytoelicit maximum amount urban slum dwellers in Abuja were willing to pay and the preferredbenefitpackage.

Method:Thestudywasamixeddesignofqualitativeandquantitativestudyinvolvingfiveurbanslums in Abuja. Quantitative datawas analyzed using descriptive statistics, statistical test andpresentedinchartsandtableswhilequalitativedatawasanalyzedandpresentedinthemes.

Result:Thestudyrevealedveryhighwillingnesstoenrollforself(78.2%)and(74.8%)forotherhouseholdmembers.Thestudyalso showed thatatpremiumN500.00only,59%of theurbanslumdwellerswerewillingtopayforCBHIwhile72.2%werewillingtopayapremiumofN400.Themaximum amount they were willing to pay was N613.77, N554.65 and N456.65 for self,householdmembersandaltruisticrespectively.Thepreferredbenefitpackagewastheonethatcoveredalldiseaseswithoutanyformofexclusion.

Conclusion:Urban slumdwellers inAbuja arewilling toutilize the social solidarity inherent incommunity financing and contribute for their healthcare needs through CBHI. These slumdwellers can willingly contribute N500 per person per month using the median price of thisstudy.Theirknowledgeandexperiencesinhealthinsurancecontributedtothedecisiontohaveabenefitpackagethatisdevoidofanyexclusion.

Recommendation:Itisrecommendedthatowningtothehighwillingnesstopayfindingsofthisstudy, theFederalCapitalTerritoryHealthandHumanServicesSecretariat should immediatelycommencetheprocessofactivatingCBHIpoolsacrosstheslumsinAbujatoeasetheiraccesstohealthcare.

Key Words: Willingness to pay (WTP), Community Based Health Insurance (CBHI), Benefitpackage,UrbanSlumsandAbuja.

Parallel Session 7-6 Health economics tools and approaches 1

Health Economics analysis in Africa: A systematic review

IrisMosweu1JanetBoadu1,PaulMcCrone11King'sHealthEconomics,InstituteofPsychiatry,PsychologyandNeuroscience,King’sCollegeLondon

Background:Thereisanincreasingneedfortheuseofeconomicanalysesinsettingprioritiesinhealthcaresystems.However,itremainsunclearhowcountriesinAfricauseeconomicevidence


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to inform policy decisions in health care, andmore importantly the availability and quality ofsuchevidence.

Aims and objectives: To review evidence of economic analysis undertaken in Africa since theyear2000.

Methods: Three main electronic databases (EMBASE, MEDLINE, PsychINFO, via the OvidSPinterface)weresearchedusingapre-definedsearchstrategywhichincludedallAfricancountriesand search terms related to economic analyses of health care. We used a free web-basedapplication;Rayyan,fortheinitialscreeningoftitlesandabstracts.StudieswereselectediftheywereconductedinanyAfricancountry,publishedinEnglish,aftertheyear2000,andundertakenany economic analyses. The CHEERS checklist was used to guide in assessing the quality ofselectedandPRISMAguidelineswerefollowedtoreportoursystematicreview.

Key findings:9,865articleswere identified fromthesearches,after theremovalofduplicates.Thereviewandidentificationofstudiesisstillongoing.

Mainconclusion(s):Reviewstillongoing

Assessing the Technical Efficiency of health Expenditures in Low and Middle-Income Countries: New Approach through the Partial Frontier Analysis

YannTapsoba,Ouagadougou-Centerforstudiesandresearchesoninternationaldevelopment(CERDI)

The paper investigates the technical efficiency of health expenditures in 87 low- and middleincomecountriesover theperiod1995-2012.Thepartial frontieranalysis isusedtoassess theefficiency scores in output and input orientations by assuming the Variable Returns-to-Scale.Two traditional inputs, such as public and private health expenditures per capita and twoenvironmentinputssuchastheurbanizationrateandtheGDPpercapitaareused.Theoutputisa composite index computed through a Principal ComponentAnalysis. The findings reveal thepresence of potential efficiency gains for the improvement of health status and for theenlargement of fiscal space of health. It appears that efforts are made in favor of healthenhancement in view of used health expenditures. The potential efficiency gains for theenlargementof fiscalspaceforhealthdeclinedoverthese lastyears.Furthermore,despitetheneedstoenlargethefiscalspaceforhealth,wefindmoreinterestingforthecountriestoaimforgreaterhealthoutcomes inviewofhealthexpenditures.Theevidences suggestpromoting theimprovementofhealthexpendituresefficiency.

Is enrolment into Ghana’s National Health Insurance Scheme pro-poor or pro-rich? Evidence from secondary analysis of Ghana Living Standard Survey round six

*EricNsiah-Boateng,**JenniferPrahRuger,*JusticeNong*SchoolofPublicHealth,CollegeofHealthSciences,UniversityofGhana,Accra**SchoolofSocialPolicy&PracticeandPerelmanSchoolofMedicine,UniversityofPennsylvania,USA

Background: Earlier studies have found enrolment into Ghana's National Health InsuranceScheme(NHIS)aspro-rich. Inrecentyears,theNHIShasembarkedonaggressiveenrolmentofthepoorandvulnerabletoreversethetide.

Objective: This paper seeks to examine equity in enrolment in the scheme to inform policydecisionsonrealisationofuniversalhealthcoverage(UHC).


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Methods: A secondary analysis of data from the sixth round of the Ghana Living StandardsSurvey(GLSS6).Thesurveywasconductedbetween18October2012and17October2013with16,774 household heads. Equity in enrolment was assessed using concentration curves andbivariateanalysistodeterminefactorsassociatedwithequity.

Findings:Participantsinthesurveyhadameanageof46yearsandmeanhouseholdsizeoffourpersons.About71%ofthehouseholdsinterviewedhadatleastonepersonenrolledintheNHIS.Households inthepoorestwelfarequintile (73%)hadenrolledsignificantly (p0.001)morethanthoseintherichestquintile(67%).Theconcentrationcurvesfurthershowedthatenrolmentwasslightlydisproportionallyconcentratedamongthepoorhouseholds,particularlythoseheadedbymales. Factors including age, sex, education, household size, region and location of residenceweresignificantlyassociatedwithenrolment.

Conclusions: Enrolment in the NHIS favours poor households but is more pro-poor in male-headedhouseholds.PolicymakerswouldhavetoensureequitywithinandacrossgenderastheystrivetoachieveUHC.

Keywords:Enrolment,Equity,NationalHealthInsuranceScheme,Ghana

Exploring the Usefulness of Discrete Choice Experiments to Explain Preferences: The Case of HIV Testing Preferences Among Truck Drivers in Kenya

MichaelStrauss,GavinGeorge:HealthEconomicsandHIVandAIDSResearchDivision(HEARD),UniversityofKwaZulu-Natal

Background: Understanding the demand for healthcare is a vital part of effective scale-up ofinterventions.However, theunderlyingpreference structures of patients and clients are oftenunknownor poorly understood.Discrete choice experiments provide a tool for researchers tobetter understand these preference structures in relation to health seeking behaviour. Thispaperexaminestheusefulnessofthistoolinthecontextofarandomisedcontrolledtrialamonglong distance truck drivers in Kenya – a particularly difficult to reach population – and theirpreferencesregardingHIVtestingandcounselling.Oralself-testinghasbeenfoundtobebroadlyacceptable inKenya, but it is unclearwhether acceptability leads tohigheruptake, andwhichcharacteristicsofself-testingdrivedemand.

Methods:Usingdatafrom150truckdriversrecruitedintotheinterventionarmofarandomisedcontrol trial, this paper examines whether the stated preferences regarding HIV testing in adiscrete choice experiment can help to explain actual test selected when offered HIV testingchoices in the context of a research study. Key characteristics of HIV testing and counsellingincludedthetypeoftest;typeofcounselling;whoadministersthetest;location;costandtime.

Results: The strongest driver of choice was cost, with participants preferring free, provider-administeredHIVtestingataroadsideclinic,usingafinger-pricktest,within-personcounselling,undertaken in the shortest possible time. Preferences diverged in two testing characteristics,betweenthosewhoactuallychoseself-testingandthosewhodidnot:thetypeoftest(p0.001)and the typeof counselling (p=0.003). Self-testerspreferredoral-testing to finger-prick testing(OR1.26p=0.005),whilethosechoosingnottoself-testpreferredfinger-pricktesting (OR0.56p0.001). Those who chose not to self-test preferred in-person counselling to telephoniccounselling (OR 0.64 p0.001), while self-testers were indifferent regarding the type ofcounselling.Therewerenopreferencesineithergroupregardingwhoadministeredthetest.

Conclusions: We found stated preference structures helped explain the actual choicesparticipantsmaderegardingthetypeofHIVtestingtheyaccepted.Offeringoral-testingmaybe


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an effective strategy for increasing willingness to test among certain groups of truck drivers.However,theimportanceofin-personcounsellingandsupport,andalackofknowledgeof,andtrust innewdiagnostic technologiesmaymean that continuing toofferprovider-administeredtesting at roadsidewellness centreswill best alignwith the preferences of thosewho alreadyattendthesefacilities.

South african multiple deprivation-concentration index quantiles differentiated by components of success and impediment to tuberculosis control programme using mathematical modelling in rural o.r. tambo district health facilities

NtandazoDlatu1,2,BenjaminLongo-Mbenza2,AndreRenzaho3RuffinAppalata4,YolandeYvonneValeriaMatoumonaMavoungou5,MbenzaBenLongo6,KennethEkoru7,BlaiseMakoso8,GedeonLongoLongo91.UniversityofKwaZuluNatal,SchoolofNursing,DivisionofPublicHealth,Durban2.Correspondingauthor:WalterSisuluUniversity,FacultyofHealthSciences,NelsonMandelaDrive,Mthatha,EasternCape3.WesternSydneyUniversity,Australia4.WalterSisuluUniversity,FacultyofHealthSciences,NelsonMandelaDrive,Mthatha,EasternCape5.UniversityofMarienNgoungou,Brazzaville,RepublicofCongo6.UniversityofPresidentKasaVubu,Boma,DRC7.UniversityofCambridge8.FacultyofMedicine,UniversityPresidentKasaVubu,Boma,DrCongo9.FacultyofMedicine,PresidentKasaVubu,Boma,DrCongo

Background: Thegapbetweencomplexities related to integrationofTuberculosis /HIVcontrolandevidence-basedknowledgemotivatedtheinitiationofthestudy.Therefore,theobjectiveofthis study was to explore correlations between national TB management guidelines, multipledeprivation concentration index quantiles components and level of Tuberculosis controlprogramme usingmathematicalmodelling in rural O.R. TamboDistrict Health Facilities, SouthAfrica.

Methods: The study design used mixed secondary data analysis and cross-sectional analysisbetween2009and2013acrossO.RTamboDistrict,EasternCape,SouthAfricausingunivariate/bivariate analysis, linear multiple regression model, and multivariate discriminant analysis.Healthinequalitiesindicatorsandcomponentofimpedimenttotuberculosiscontrolprogrammewereevaluated.Results:Intotal,62400recordsforTBnotificationwereanalyzedfortheperiod2009-2013.TherewasasignificantbutnegativebetweenFinancialYearExpenditure(r=-0.894;P=0.041)SeropositiveHIVstatus(r=-0.979;P=0.004),PopulationDensity(r=-0.881;P=0.048)and the number of TB defaulter in all TB cases. It was shown unsuccessful control of TBmanagement program through correlations between numbers of new PTB smear positive, TBdefaulternewsmearpositive, TB failureall TB,PulmonaryTuberculosis case finding indexanddeprivation-concentration-dispersionindex.ItwasshownsuccessfulTBprogramcontrolthroughsignificantandnegativeassociationsbetweendecliningnumbersofdeathinco-infectionofHIVandTB, TBdeathsall TBandSMIADgradient/deprivation-concentration-dispersion index. Themultivariate linear model was summarized by unadjusted r of 96%, adjusted R2 of 95 %,StandardErrorofestimateof0.110,R2changedfor0.959andsignificanceforvariancechangefor P=0.004 to explain the prediction of TB defaulter in all TBwith equation y= 8.558-0.979 xnumberofHIVseropositive.Afteradjustingforconfoundingfactors(PTBcasefinding index,TBdefaulternewsmearpositive,TBdeathinallTB,TBdefaulterallTB,andTBfailureinallTB),onlyHIVandTBdeathandnewPTBsmearpositivewereidentifiedasthemostimportant,significant,and independent indicator to discriminatemost depriveddeprivation-concentration-dispersionindex far from other deprivation-concentration-dispersion quintiles 2-5 using discriminantanalysis.


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Conclusion:Eliminationofpovertysuchasovercrowding,lackofsanitationandenvironmentofhighestburdenofHIVmightendtheTBthreatinO.RTamboDistrict,EasternCape,SouthAfrica.Furthermore, ongoing adequate budget comprehensive, holistic and collaborative initiativetowardsSustainableDevelopmentalGoals(SDGs)isnecessaryforcompleteeliminationofTBinpoorO.RTamboDistrict.

Keywords:Tuberculosis,HIV/AIDS,Success,Failure,Controlprogram,Healthinequalities,SouthAfrica

The nigerian health economist’s unplayed role in securing primary health care for all

EmmanuelNdenorSambo1,HyeladziraGarnvwa-Pam2,DrFanenVerinumbe21NigeriaStateHealthInvestmentProject,TarabaStatePrimaryHealthCareDevelopmentAgency2NationalPrimaryHealthCareDevelopmentAgency

Background: Asmost African countries and the rest of theworld continue to spendmore onhealth,corresponding increase in the intendedgeneralhealthoutcomescannotbeconfidentlysaid to have been achieved. There is a general consensus on the need to rejig the healthfinancingstrategiesthathavebeenemployedbyvariousgovernmentsinthedevelopingworld.

Thereexistsachasm,asortofsystemicvaguenessintheguidanceofhealthfinancingpolicy.Thisineffecthasallowedpolicymakerstomakerathermisguideddecisionsthatsuggestanabsoluteabsenceatworseandan irrelevanceat the leastofhealtheconomistson thedecision-makingtabletoinformpolicies.

Objectives: This paper aims primarily to simulate thinking around how health economists inAfricancountriescantakeafrontrowseatinguidinganevidencedrivendecisionmakingprocessinkeepingwithglobalbestpracticesastheworldsteerstowardsUniversalHealthCoverage.

This study aimed to assess the quantity, quality and targeting of economic evaluation studiesconducted in the Nigerian context and the extent to which they translate to effective healthpolicies.

ItfurtherpointsoutsomeareasthatthehealtheconomistinAfricahasleftunattendedtoatthedetrimentofthewholehealthsystem.

Methods: A comparative review of Nigeria’s health systems’ institutionalized policy makingprocesses was employed as well as a systematic review of full economic evaluation studiespublished between 1998 and 2018 in international and local journals. where informationregarding global best practices that are not practiced in the African setup were elicited andbroughttobare.

Key Findings: Even though most African countries have pockets of Health Economists withtechnical capacity to provide the much required guidance to policy makers, the institutionalplatformforsuchtechnocratsisunavailableoratbestweak.

Conclusion: For the African Health System to reach set targets, in this case Universal HealthCoverage, theHealth Economistmust takeup the responsibility of providing thehealthpolicymakerandimplementerwithempiricalevidenceinformedguidance.


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Using the EquityTool to Determine Socio-Economic Status in the Kintampo Health Demographic Surveillance Area: A Feasibility Study

Kwame Adjei1, Irene Azindow1, Felix Boakye Oppong1, Andrea Sprockett2, Nirali Chakraborty2, YeeteyEnuameh1&2,KwakuPokuAsante1,SethOwusu-Agyei1&41KintampoHealthResearchCentre2KwameNkrumahUniversityofScienceandTechnology3MetricsforManagement4UniversityofHealthandAlliedSciences

Background:Wealth isaknownhouseholdcharacteristicthat largelyaffectshealthparticularlyin Sub-Saharan Africa. The wealth index was developed in 2001 as a reliable way to captureSocio-economic Status (SES) based on asset ownership and household characteristics usingprincipalcomponentanalysis(PCA).

However,theWealthIndexquestionsarelengthy(25-50questions),time-consuming,andoftendifficult to analyse. To address these challenges, the EquityTool was created by Metrics forManagement(M4M)andpartners.TheGhanaEquityToolsimplifiesthefullDHSWealthIndextocollect13highly significant country-specificquestions. It alsooffersautomatedcalculationsonStataandSPSS.Itbenchmarksresultstonationalpopulation

TheKintampoHealthResearchCentreisoneofthreeresearchcentresinGhana.ThecentrehasaHealthandDemographicSurveillanceSystem(KHDSS)whichcapturesvital includingSES.TheSES questionnaire is however lengthy and calculated using the regular PCA method with itschallenges. It isalsonotbenchmarkedtonationalpopulation.Toaddressthesechallengesandachieveuniversalhealthcoverage,KHRCincollaborationwithM4MpilotedtheEquityToolundertheContinuumofCare(CoC)project.TheCoCprojectwasafamilyplanning(FP)implementationresearchwhichmadeuseofacardandstarstoencouragewomen(15-49)touseFP

Objective: Topilot theEquityTool and comparewith the standardKHDSSquestionnaireundertheCoCproject

Methods:ThiswasacrosssectionalsurveycarriedoutbetweenFebruarytoMarch2018usingResearchElectronicDataCapture (REDCap)aspartofprojectendline.Womenof reproductivehealth age were sampled using the KHDSS which covers predominantly rural communities inKintampo North and South districts where the CoC tudy was implemented.Wealth index forparticipantswasmeasuredusingtheequitytoolandthestandardKHDSSquestionswhichwereboth incorporated into REDcap. Twomeasures of agreement namely, percent agreement andCohen’sKappawasusedtoassesstheagreementbetweenthetwosetofitems

Results: The percent agreement between the equity tool and the KHDSS questionnaire was43.84%.AfairCohen’skappaof0.298wasobtained.Kappa>0.75isexcellent

Conclusion:TheEquityToolwaseffectivelyusedtomeasurewealthindex.ThefairKappacouldbe attributed to the fact that the KHDSS questions are targeted primarily towards ruralcommunitiesandnotbenchmarkedtothenationalpopulation.

AlthoughtheagreementbetweentheKHRCquestionsandtheEquityToolquestionswasfair,thelatterispreferredsinceitisbenchmarkedtothenationalpopulation.


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Estimating the direct medical costs of Helicobacter pylori eradication therapy for outpatient primary care in Cameroon: implications for quality care and universal health coverage

JeannineAminde,LeopoldAminde

Background:Almosthalf theworld’s population is infectedwithHelicobacterpylori (H.pylori)with the highest reported prevalence from Africa. This infection is associated with severalmorbid gastrointestinal conditions and the World Gastroenterology Organization (WGO)recommendstestingfordyspepticpersonsandthetreatmentofpositivecases.Despitethehighprevalenceandrelatedburdenofthisinfection,thecostoftreatmentinpatientswithdyspepsiainprimarycaresettingsinCameroonisunknown.

Methods:ThiswasaretrospectivereviewofoutpatientrecordsfromJanuary2012toDecember2016attheWumDistrictHospital,intheNorthwestregionofCameroon.WereviewedrecordsofallpatientsforwhomH.pyloriserologytestwasrequested.Costofillnesswasestimatedfromthepatient’sperspectivebasedonhospitalstipulatedcharges.

Results:Weincluded451patients,63.6%(n=287)femalesandmeanagewas40.7years.OverallH. pylori seroprevalence was 51.5% (95%CI: 47% – 56%). Themost used eradication regimenwas;omeprazole+amoxicillin+metronidazole(53.9%ofseropositivepersons).Theuseoffirstlineclarithromycin-basedtherapywaslow(18.5%)anddecliningacrosstheyears.Themeancostof eradication therapy was 11,415 ± 5,507 FCFA; this ranged 8,200 FCFA (for omeprazole +amoxicillin + metronidazole therapy) to 21,000 FCFA (for clarithromycin triple therapy). Theaveragetotalcostoftreatmentfordyspepticoutpatientswas8,357±4,211FCFA,(range:5,900to21,510FCFA).

Conclusion:Our study shows that one in every twodyspeptic people haveH. pylori infection.WelloverathirdofCameroonianslivebelowthenationalpovertyline(44.8%belowthelowermiddle income class poverty line), and the average cost of outpatient treatment forH. pyloriinfection inprimarycareaccountsforathirdofminimumwageinCameroon(36,270FCFA). Inthe absence of universal health coverage, this has significant implications for Cameroon, ashealthcare costs are reliant on out-of-pocket payments with potential to exert catastrophichealth expenditure if broader perspectives, hospitalization and disease complication costs aretakenintoaccount.

Keywords:Helicobacterpylori,seroprevalence,cost,primarycare,Cameroon


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ParallelSession8–OralPresentations

Parallel Session 8-1 Resource allocation, efficiency and management 2

Setting up an adequate information solution to strengthen primary health care in Mauritius.

DR.LaurentMUSANGO¹;Mr.PremduthBURHOO²;Dr.FaisalSHAIKH¹;DR.MaryamTIMOL³¹WorldHealthOrganisation,CountryOfficeofMauritius.²MauritiusInstituteofHealth(MIH)³MinistryofHealthandQualityofLife(MOHQL)

Introduction:MauritiushasoneofthebestcivilregistrationsystemsinAfricawithalmost100%birthsanddeaths recorded.Morbidity conditionsandmortality causesare codedaccording tothe 10th Revision of the WHO International Classification of Diseases (ICD-10). The HealthStatistics Report published annually contains information on population and vital statistics,infrastructureandpersonnel,morbidity,mortalityandtheactivitiesofalmostallhealthservicespertainingtotheRepublicofMauritius.HealthServicesStatisticsReportsarecompiledyearly.AtthePHC level,aregistry ismaintainedwhichcontainsdemographicandclinical informationonpatientsattendinghealthfacilities.However,itwasnotedthattheinformationcollectedarenotdesigned toprovidedata fordetailedanalysisandarenotmadepublic forappropriateusebydecisionmakers.ReasonwhyanassessmentonanadequateinformationsolutiontostrengthenprimaryhealthcareinMauritiuswasinitiated.

Methodology:Thecountryassessmentstartswithathoroughanalysisofthesituationofhealthinformation systemover the past 15 years. Challenges or present opportunities for improvinghealthinformationsystemwerethencarriedout.Aparticipatoryandflexibleapproachwasusedforthisassessment;amultidisciplinaryteamwassetuptocarryouttheassessment.AWorkingGroup (WG) of 5 members was constituted to review and to validate the report. The reportidentifiedkeysopportunitiesthatthecountrymaycontinuetobuildonaswellaschallengesandpossible solutions for adequate information solution to strengthen primary health care inMauritius.

Results:TheassessmentidentifiedopportunitiesmentionedaboveandchallengesthatneedtobemitigatedforimprovingPHCinthecountries. Thechallengesidentifiedare:datageneratedby the health system is not exploited to its full potential, there is inadequatemonitoring andevaluation of health interventions, modern information solutions are not available for betteranalysisoftheexistinginformation,andthequalitycontrolmeasureshavenotbeendesignedtomeasuretheoutcomesatindividualandfacilitylevels.

Conclusion and recommendations: The assessment recommended to implement strongintegratedHealthManagementInformationSystemsbyintroducinge-healthwherebyallhealthinformationsystemsareintegratedwithaneffectiveinteroperablepatientdatatransfersystem,consideringintroductionofasmarthealthcardconcerningallpersonalhealthinformationatthe


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differentlevelsofthehealthsystemincludingperipherallevelandsettingupastrongmonitoringandevaluationsystemstostrengthenprimaryhealthcare.

Identifying priority health system strengthening actions through a participatory approach for addressing non-communicable disease crisis in Mauritius

DrFaisalShaikh,MrPremduthBurhooWorldHealthOrganization Background:Non-communicable diseases (NCDs) are the leading cause of death, disease anddisability inMauritius. The fourmajor NCDs (cardiovascular diseasemainly heart disease andstroke,cancer,chronicobstructivepulmonarydiseasesanddiabetes),accountfornearly81%ofalldeaths1and85%of thediseaseburdenandtrends inprematuremortalityandrisk factorsareputtingincreasingstrainonhealthsystems,economicdevelopmentandthewell-beingofthepopulation.

AimsandObjectives:Theaimofthisassessmentwasto identifyhealthsystemchallengesandopportunities

1. ToassessthecoverageofkeypopulationandindividualNCDinterventionsandidentifythehealthsystemchallengesresponsibleforstatusofcoverage.

2. Toproducenationalpolicyrecommendationsforstrengtheningthehealthsystem

Methodsused:AnadaptedversionofthestructuredhealthsystemassessmentguidedevelopedbyWHO-EUROwasused.Thetoolidentifiedfifteenhealthsystemsfeaturesandsemistructuredquestions is used to assess the health system performance. This approach also gives a clearunderstandingofcoreinterventionsandservicescoverageandfinallyidentifyingthosefeatureswhich most significantly impact the coverage of these interventions Participatory approachesand deliberative engagement methods were used for qualitative assessment. Secondary datawasusedforquantitativeanalysisNationalstakeholderswereengagedthroughparticipationinworkinggroupsandNationalconsultations.

Key Findings: Progress has beenmade in scaling up a number of coreNCD interventions andservices. Despite the progress increasing trend is noted in mortality due to NCD. The risk ofprematuremortalityduetoNCDsis22.5%ishighascomparedtootherdevelopedcountries.Thecoverageofmanycorepopulation interventionswas foundto range from limited tomoderateandcurrentpopulationexposuretoriskfactorsforNCDsremainsamajorconcern.Thecoverageof individual services is much better although risk stratification for CVD, and early detection,managementandfollow-upofNCDpatientsneedfurtherimprovements.

The health system features identified as major challenges for population interventions are“interagencycooperation”and“explicitprioritysettingapproaches”Forcoreindividualservices,“integrationofevidenceintopractice”isthegreatestchallenge.Otherbottlenecksforbothare“population empowerment”, “adequate information solutions”, “ensuring access and financialprotection”and“humanresources”.

Main conclusions: Seven health system action areas are identified to accelerate the gains forbetterNCDoutcomes.ThiswillfeedintothedevelopmentofHSSP.Assessmentalsoopenednewwindowforbetterparticipatoryapproachforpolicydevelopment.


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Who Are We? The Role of Team, Professional and Managerial Relationships in Collective Leadership Practices in District Hospitals, Cape Town, South Africa

*DicksonROOkello,**GerryMcGivern,*LucyGilson*UniversityofCapeTown**WarwickBusinessSchool

Background:Effectivehealthcareleadershipisnecessaryinengagingwithotherstakeholdersinmoving towards universal health coverage (UHC) in Low-and-Middle-Countries (LMICs). Toachieve UHC, hospitals are important in the provision of quality people-centred healthcare.Hospitalsarecomplexsocialsystems,whereleadershipisacollectivephenomenon,practicedbydifferent healthcare cadres. In such environments professional, work and social identities atgroup,relationalandorganisational levelsare likelyto influencehowleadership ispracticed.Arich evidence base, and relevant theorisation, is needed to understand the nature andconsequencesof leadershippractices inLMICs.Yet,hospital leadershiphasrarelybeenstudiedin South Africa. This paper presents findings from a qualitative study on healthcareorganisationalcontext,leadershippracticesandeffectiveleadershipindistricthospitalsinCapeTown.

Methods:Weusedqualitativeapproachestodatacollectionintwocasestudydistricthospitals.Wehada total of 42 in-depth interviewsand two focus groupdiscussions. Wealsoattendedmanagementmeetings,madeobservationsindifferentareas,andreviewedinternalmemosandlettersof relevance to the leadershippracticeswithin thehospitals.Our respondents includedclinicians,nurses,alliedhealthworkers,frontlineworkersandadministratorsatvariouslevelsofmanagement.Our analysiswasboth inductive anddeductive to explore andexplain emergingissuesaboutcollectiveleadershippracticesinhospitals.

Results:Ourstudyrevealedthatrespondentsemphasisedtheirrolesascliniciansandnursesfirstand as leaders, second; and that work team, professional and managerial identity andrelationships are critical to leadership practices, and their likely influence on staffmotivation.Respondents linked collective leadership practices and relationships to the common goal ofprovidinghealthcareservices.Seniorclinicianswereawareoftheirprofessionalidentityandhadloyaltyto,andcollegialrelationshipswithjuniorclinicians.Professionalidentityandprideamongclinicians allowed them to exercise their leadership practices in a collectivemanner and theyconsidered themselves more motivated as compared to their nursing colleagues. Nurses inmanagement positions also viewed the transfer of leadership and professional skills tocolleagues as an important way of sharing professional experiences. However, junior nursesviewedtheprofessionalhierarchiesinnursingasgivingthemfeweropportunitiestoparticipateincollectiveleadershipandsawthisasunderminingtheirmotivation.Inaddition,thestructuringofmanagementintojunior,middle,andseniorlevelsdepictedmanagementidentitieswithinthehospitalthatcreatedbarrierstorelationshipbuildingandcollectiveleadershippractices.

Conclusion:Cliniciansandnursesholddualprofessionalidentitiesinhospitalsandthisinfluencestheirleadershippractices.Collectiveleadershippracticeshaveinfluencesoverhealthcareworkermotivation. To build leadership practices that are inclusive, policymakers and practitionersshouldaimatdeliberateeffortstoconsiderteam,professionalandmanagerialdifferenceswhendesigningandimplementingleadershipdevelopmentprogrammeswithinthehospitalasbothaphysicalandenactedcontextwhereleadershippracticesaresituated.


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Tanzanian’s revision of Standard Treatment Guidelines and National Essential Medicines List

GavinSurgey,PRICELESS/WitsSchoolofPublicHealth

Objective: TheMinistry of Health in Tanzania undertook a systematic process to revise theirStandard TreatmentGuidelines andNational EssentialMedicines List (STG/NEMLIT) led by thePharmaceutical Services Unit (PSU) under the Tanzanian Ministry of Health. Listed essentialmedicinesareconsidered tobeoneof themost cost-effectiveelements inhealthcareandareused as tools to promote health equity. These need to be regularly updated to ensure theycontainkeycommoditiesandthattheyreflectuptodateevidenceoneffectivenessandsafety.

Methods: The revision process of the STG/NEMLIT was structured around capacity buildingactivitiessuchthattheTanzanianteamcouldundertakethemajorityoftheworkthemselvesandthis could be a product developed in-country. Training and support in health economics wasprovidedonevidencebasedmedicineandcostingforprioritysettinginmedicines.Theprocessinvolvedcapacitybuildingworkshopsandon-goingengagementbetweentheTanzanianexpertreview team and continuous technical support fromHTA experts contracted to PRICELESS SA.Such engagement enabled in-country stakeholders to gain an in-depth understanding andpracticalexperienceofevidence-basedselectionofmedicineswhile simultaneouslydevelopingtheirknowledgebaseontheprinciplesofHTA.This linkedtotheHTAprocess,againprovidingtheaffirmationthatHTAhasacriticalroletoplayindecisionmaking.

Outcomes: Beyond the revisedSTG/NEMLITwhichwas completedat thebeginningof2018, aguidancedocument in the formofaStandardOperatingProcedure (SOP),wasdevelopedbyagroup of national and international experts aimed at providing systematic guidance fordeveloping and reviewing the STGs, vertical program treatment guidelines and associatedmedicine lists (NEMLIT inclusive), that could be reproduced for another review process. Therevision process and capacity building improved skills relating to HTA which in turn helpedprecipitateTanzaniainestablishinganHTAcommittee.

Discussion and conclusions: The guidelines outline the approach to the review and how toprioritisetopicsfocusedonforreview.Anotableaspecttotheguidanceistheincorporationofcost-effectiveness in considering medicines or treatment options. While there is no directreferenceonhowtoestablishthresholdsforinclusionorexclusionofmedicines,thisisthefirsttime that the guidance for the development of the STG/NEMLIT has incorporated in cost-effectiveness.ItalsoprecipitatedtheestablishmentoftheHTAcommitteewhichwasformedin2017.

Service delivery planning in resource constrained settings: evidence from Nigeria

KelechiOhiri,MusleehatHamadu,YewandeOgundeji:AbujaHealthStrategyandDeliveryFoundation

Background:Many states in Nigeria develop yearlyminimum service package (MSP),which isintended to improve access by ensuring uniformity in resource availability by facility type andstandardizationinqualityofcareprovisionforitscitizens.Despitethis,servicedeliveryinNigeriaisstillbelowparbecausemanyoftheseMSPsareneitherfeasiblenorefficientduetotheinputfocused approach (costs per service delivery points) that stretches resources beyond fiscalrealities. There is a need to shift from an input basedMSP to an output focusedmodel thatconsiders tradeoffsof resourcesandpotential impact toallow states tooffer to their citizens,accesstobasichealthservicesdespitefiscalconstraints.Thisproposedmodelwouldbeanovel


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approach,whichwouldneed tobedevelopedand testedwith respect to its acceptability andutilitywithdecisionmakers.

Aims:Thisstudyhad2aims:

o Todevelopanddesignrealisticoutputfocusedservicedeliveryplan(SDP)whichconsiderneeds,resources,priorities,andarealisticallyachievabletimeframeinKadunastate.

o Tointegratetheapproachintothestate’splanningprocess.

Methods:Thestudywasconductedjointlywiththestate.Theoverallapproachissummarizedin3keysteps:

1. Thefiscalspacewasprojectedacross3resourcescenarios,alowcase,basecaseandhighcase,todeterminetheextentofresourcesavailable

2. A comprehensivemodel was designed usingMicrosoft Excel, which allowed us todetermine theefficient combinationof inputs (e.g.maximumallowablenumberoffacilities,HRHnumbers)necessarytoachievedesiredserviceaccess.

3. The range of allowable model options that fit within the determined constraintsbased on financial projections were presented to the policy makers and Statedecisionmakerstoco-selectthemostviableservicedeliveryplan.

Findings: Our findings demonstrate the efficiency of the SDP. One of the SDP models wasprojectedto increaseaccessto69%atacostofN7.9b(US$25m),whichwaswithinthestate’sresourcelimitcomparedtoMSPwhichofferedincreaseinaccessto80%atacostofN60b.PolicymakersshowedstrongsupportfortheSDPbyintegratingintokeystrategicdocumentssuchasthe state strategic health development plan. The Executive Governor of Kaduna state alsoapproved the implementationofoneof themodelsby issuingadirective to theStatePrimaryHealthcareAgency(SPHCA)torecruit1MedicalOfficerperLocalGovernment intothesystem,oneofthecornerstonerecommendationsfromtheSDPmodels.

Conclusion: This study demonstrates the need to shift from input driven models to outputfocused models when designing healthcare service delivery models. It provides an analyticalapproach towards resource allocation for PHC service delivery. In the context of resourceconstrained settings, it provides decision makers options to optimize health systems servicedelivery.

The role of efficiency gains in expanding fiscal space for health in Nigeria

YewandeOgundeji,KelechiOhiri,BabatundeAkomolafe:HealthStrategyandDeliveryFoundation

A major component of achieving universal health coverage in many developing countries isreducing out-of-pocket (OOP) expenditurewhich is a critical demand side barrier to accessingcare. Nigeria has the highest OOP expenditure in Africa and government health spending isbelowparcomparedtorecommendedbenchmarks.Giventhecorrelationbetweengovernmentspendingandimprovementinhealthoutcomes,itsimportancecannotbeoveremphasized.ThisstudysoughttoexploreandidentifyviableoptionstoincreasehealthspendinginKadunastate,Nigeria.

Our study involved qualitative and quantitative approaches. First, we developed a conceptualframeworktoexplorefiscalspaceforhealth.Thisincludedacomprehensivereviewofliteratureand theoretical frameworks. Our framework consisted of 6 thematic areas: macroeconomicgrowth, reprioritization of health, health sector specific sources, developmentalassistance/grants, public private partnerships and efficiency gains. Second, we conducted key


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informant interviews with 13 participants including public expenditure experts and seniorprogrammanagersandpolicymakers.Third,weconductedaquantitativedeskreviewtoinformour revenue projections and the feasibility of the identified fiscal space options. Data sourcesincludedauditedreports,governmentbudgetandexpendituredata,householdsurveys,healthaccountsurveys,annualexpenditurereports,andeconomicgrowthdata.

Buildingonpreviousanalysisofthehealthneeds inthestate, inadditiontothecurrenthealthspending, ₦16bn is required to fund the health system.We found that the health sector canobtaina₦5.2bnif80%ofbudgetperformanceisachieved;premiumpaymentsfromaplannedsocialhealth insuranceschemecouldgenerateanadditional₦2bn;andearmarkedtaxescouldpotentiallygenerate₦1.5bn.However,healthbudgetperformancehasbeenpoor(anaverageofabout 50% over the past 5 years) and implementing health insurance or earmarking taxesrequire legal frameworks and careful design that are time and resource consuming. Efficiencygains in terms of improving health budget performance appears to be the most feasible,sustainable,andcosteffectivefiscalspaceoptionfortheState.Toobtainpotentialrevenuefromthisoption,thestateministryofhealth(SMOH)andotherhealthagencieswouldneedtoliaiseand frequently engage with the ministry of budget and planning and finance to effectivelycommunicatetheneedtoprioritizehealthintermsofbudgetreleaseforthesector,whichcanbeachievedbyprovidingmeasurableevidenceof impact, value formoney, andaccountabilityforpreviouslydisbursedfunds.

Parallel Session 8-2 Public health research issues

Limited health status awareness and biased equity estimates in LMIC

IgnaBonfrer,Prof.EddyvanDoorslaer,ErasmusSchoolofHealthPolicy&Management

BackgroundEquityinprimaryhealthcaredeliveryisanimportantsteponthepathtowardsUHCandisapivotalresearchtopicforhealtheconomists.Acommonapproachtoquantifyequityistomeasuretheextenttowhichhealthcareutilizationisrelatedtothemeasureofinterest,suchasincome,education,ageorgenderaftercontrollingfordifferencesinneeds.Healtheconomistsrely heavily on self-reportedmeasures of general health status or specific conditions to proxytheseneeds.However,thevalidityofthistechniquedependslargelyontheadequacyofthisself-reportedhealth.

AimThisstudyaimsinthefirstplacetodeterminetheextenttowhichrespondentsareawareoftheirownillhealthstatus,secondtoidentifythepotentialbiasinself-reportedhealthstatusandfinally to indicatewhether thebias in self-reportedhealth statusdiffers systematicallybyage,gender,incomeoreducationlevel.

Methods Using three unique datasets from the Health Insurance Fund collected in Nigeria(Kwara State, n=2325households), Tanzania (Dares Salaam,n=674households) andKenya(Nandi district, n = 1242 households). We match self-reported with objective measures(anthropometrics and/orbiomarkers) for five conditions:hypertension,diabetes,underweight,overweightandmalaria.Weusetheassociatedhouseholdsurveydatatomeasureage,gender,consumptionexpenditureasaproxyforincomeandeducationlevel.

KeyfindingsPreliminaryresultsshowthatrespondentssignificantlyunderestimatedtheirownillhealth, with regard to hypertension (15% was hypertensive but did not report this) and


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overweight (20%didnot report this),while theyoverestimated theprevalenceofmalaria (8%incorrectlyreported)andunderweight(5%incorrectlyreported).Wefindthatpeopleabove40yearsofage,malesandthosewithnooronlyprimaryeducationaremore likely to incorrectlyreport no ill health. Preliminary results suggest further that there is no significant incomegradientinfalsenegatives.

ConclusionWitheightypercentofmortalitycausedbycardiovasculardiseasesoccurringin lowandmiddle incomecountriesandhypertensionandoverweightamongthemainrisk factorsofthisdisease,thesefindingsshowtheimportanceof improveprimaryhealthcareaccess.This isalso a cautionary tale for health economists, using self-reported health status as a proxy forhealth,whichmay leadtoanunderestimationof inequity in thehealthcaresystem,especiallytowardsmen,theelderlyandthosewithlimitedlevelsofeducation.

Risky Sexual Behaviour of Youth in Rural Areas of Nigeria: Implications for Primary Health Centres

JulianaC.Onuh,AloysiusOdii,ChukwuedozieK.Ajaero&ChimezieAtamaDepartmentofGeography,UniversityofNigeriaNsukka

BackgroundYoungpeopleresidinginbothurbanandruralareasofNigeriaareknowntoindulgein risky sexual behaviour. Meanwhile, interventions aimed at curbing these behaviours easilyreach urban areas thereby leaving Primary Health Centres (PHCs) in rural areas with theimportantresponsibilityofhealthpromotionanddiseaseprevention.However,PHCswouldfindthe delivery of this duty more tasking without evidenced knowledge about the categories ofyouthpronetoriskysexualbehaviour.

ObjectiveTheobjectiveofthisstudyisthereforetoexaminethespatialriskysexualbehaviourofyouthresidinginruralareasofNigeriaandthesociodemographicfactorsaffectingthem.

MethodDatafromNigerianDemographicandHealthSurveyof2013conductedinall36statesofNigeriaandAbujawereused.Witha sampleof8788youngpeopleaged15-24years.Riskysexualbehaviourwasmeasuredusingthreeitems;nonecondomuseatfirstsexualintercourse,none consistent condom use and multiple sexual partners. The data was analysed usingdescriptivestatistics,chi-Square,hotspotandbinarylogisticregressionanalyses.

ResultsBasedonthechi-squareanalyse,resultfromthisstudyrecordedsignificantvariationsinrisky sexual behaviours across rural areas with major hotspot in NorthWest Nigeria. Highestprevalenceofmultiplesexualpartnerships,nonecondomuseandthan15yearsageatfirstsexwere found in South South, NorthWest and NorthWest Nigeria respectively. Finally, binarylogisticregressionidentifiededucation,maritalstatus,regionandageasdominantriskfactorsofriskysexualbehavioursacrossregions.

ConclusionTheseresultsthereforesuggestthatsincePrimaryHealthCentresinruralareashavethe primary duty of health promotion and disease prevention, region specific programmesmeanttocreateawarenessontheimportanceofsafesexandcondomuseshouldbetargetedatyouthswithloweducationalstatusandthosewithinpoorwealthcategorywithmajoremphasesonvulnerableregions.

Utilization of primary health care in Nigeria: A quantile regression analysis using the Service Delivery Indicators Survey Data

OpeyemiAbiolaFadeyibi,WorldBank,Nigeria


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Thepaperusedquantile regressionanalysis toexplain factors thataffectutilizationofprimaryhealthcareservicesatdifferentpointsontheconditionaldistributionofthedependentvariable.Health facility data from the ServiceDelivery Indicators (SDI) survey forNigeriawas analyzed,measuringutilizationas thenumberofoutpatientvisits in the3monthspreceding thesurvey.Thepaperusedbothordinaryleastsquare(OLS)regressionandquantileregressionanalysesatthe 10th, 25th, 50th, 75th and 90th quantiles to see if there are differences in the estimatesproduced by both approaches. Quantile regression (QR) was used to estimate the effect ofexplanatoryvariablesonthedependentvariableatdifferentpointsofthedependentvariable’sconditionaldistribution

Results showed that health facility type, region, provision of family planning services andavailabilityofelectricitysignificantly increasesutilizationofhealthfacilitiesacrossallquantiles.Theeffectsofthesefactorsonutilizationarehoweverhigher intheupperquantilethaninthelower quantile. In addition, availability of infrastructure such as toilet and water, as well asfrequency of facility operations (opening daily or not) significantly increases utilization in theupper quantile. Understanding the pattern of effects of factors at different points of theconditional distribution of utilization of primary health care is key to strengthening primaryhealthcaresysteminNigeria.

Characterization of 331G/A polymorphism of RP gene and identification of viral oncogene HMTV virus as genetic markers for the improvement of breast cancer management in Cameroon.

NIELSNGUEDIAKAZE1,N.N.K.,JEANPAULCHEDJOU1,J.P.C.,WILFREDMBACHAM1,2,W.M.UniversityofYaoundéI(DepartmentofBiochemistry/BiotechnologyCenter,Yaounde,Cameroon)FacultyofmedicineandBiomedicalSciences

Background:Breast cancer is a real public healthproblem inCameroon,wheremorepatientswiththiscancerusuallydieayearafterdiagnosis,asitisstillbasedonhistologicalexamination,mortality due to cancer is far from decreasing. Since cancer is an accumulation of molecularchanges, the+331G/ApolymorphismofPgRgene (progesteronereceptor)andviraloncogeneHMTV (HumanMammary Tumor Virus) has been recently considered as amolecularmarkersassociatedwithbreastcancer.Duetothatwefixedourobjectivestocharacterizethesemarkers.

Aim and objectives: characterization of +331 G/A polymorphism of PgR gene (progesteronereceptor) and viral oncogene HMTV (Human Mammary Tumor Virus) by semi-nested PCR tounderstandetiologicalfactorofthatcancerinCameroon.

Method:We carriedout a case control study, inwhich26 casesdiagnosedpositive forbreastcancer at the CHU of Yaoundewere recruited through the identification of archived biopsies.Bloodsampleswerealsocollectedfrom20womenrecruitedusingaquestionnaireandainformconcern sign by each of them. +331 G/A polymorphism in the PgR gene was identified usingNIaIVendonucleasebyPCR-RFLP,andHMTVviraloncogenebyhemi-nestedPCR.ThedatawereanalyzedusingMicrosoftExcelandSPSSv20.

Results:Wegotameanageof57,73+/-9,87inourcancerousgroupwiththepredominanceofinfiltrantductcarcinomaatgradeIIofSBR.AnOddRatioof1.268withConfidentIntervalof95%1.004-1.664provingthatthereisasignificantassociationbetween331G/Amutationandbreastcancerwith P-value of 0.026, obtained by comparing themutant group (AA) 28,5% andwildgenotype (GG). Inaddition,3casesweredetectedwith theHMTVvirus,onewas found in thecancergroupandtwointhecontrolgroup.

Conclusion:Theseresultsindicatethat,HMTVisconsideredasviralcauseandcanpredisposetobreastcancer,beside331G/Apolymorphismisanassociatedriskfactorofthatcancer.


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Evaluating the Impact of South Africa’s Ideal Clinic Realisation Programme using Quasi-Experimental Methods

Ijeoma Edoka, Nicholas Stacey and Karen Hofman: PRICELESS SA, School of Public Health, University ofWitwatersrand,Johannesburg,SouthAfrica, Background: South Africa is at present re-structuring its healthcare system with the aim ofachievinguniversalhealthcarecoveragethroughasingle-payerNationalHealthInsurance(NHI)scheme.TheNHIwasintroducedasonesolutiontoinequalitieswithintheSouthAfricanhealthcaresystembycreating ‘aunitarysystem,financedthroughacentral fund,wherepatientscanselectfromapackageofcareofferedbyaccreditedhealthfacilities’.InpreparationfortheNHI,anumber of reforms have been introduced to improve both access and quality of health careservices in public health facilities. Given the importance of having a well-functioning primaryhealthcare system, these reforms have also targeted improvements and restructuring of theprimaryhealthcaresystem.Animportantcomponentoftheprimaryhealthcarereformswasthephased introductionof the IdealClinicRealisationProgramme (ICRP) in2014.Thisprogrammewas accompanied by a wide range of initiatives aimed at improving the quality of primaryhealthcareservices,particularlyinmoredeprivedareas.TheICRPtargetedimprovementsinPHCadministrativeprocess;healthservicedelivery;humanresourcesforhealth;andinfrastructure.

Aim: This aim of this study is to assess the impact of the ICRP on the quality of primaryhealthcareservices.

Method:Weuseadministrativedata–theSouthAfricanDistrictHealthInformationSystemandapplyquasi-experimentalmethodstoassesstheimpactoftheprogrammeonamenablecausesofdeath(aproxyforqualityofhealthcareservices)andprocess indicators(includingessentialmedicationstock-outrateandpatientsafetyincidentcases).Thesequasi-experimentalmethods(difference-in-differencecombinedwithpropensityscorematching)allow for the identificationof causal effects of the programme on both population-level outcomes (amenable causes ofmortality) and process indicators. This will provide useful insights to decision-makers onimprovementstobemadepriortofullscale-upoftheprogramme.

Health state utility values among children and adolescents with disabilities: A systematic Review and Metaanalysis of the evidence

*LucyKanya,**Dr.NanaAnokye:*LondonSchoolofEconomicsandPoliticalScience,**BrunelUniversityLondon

The assessment of healthcare technologies and interventions requires the assessment of bothcostsandutilities.Healthstateutilityvalues(HSUVs)aremeasuredusingarangeofgenericandconditionsspecificmeasures.WhilereviewshaveidentifiedthatgenericmeasuresofHSUVsmaylackvalidity inadultswithconditionsthatresult inphysicaldisability,there is little informationavailableonthemethodsusedtoobtainHSUVsinchildrenandadolescentswithdisabilities.TheobjectivesofthissystematicreviewaretodescribethemethodsusedtoobtainHSUVs,includingmodeofadministrationandpsychometricproperties,andprovidesummarystatisticsforHSUVsamongchildrenandadolescentswithdisabilities.Anarrativesummaryoftheavailableliteratureis provided. In addition, using a random effects model, the costs and utilities are pooledseparatelyforcombinedmeasuresofeffect.Anetworkmeta-analysisofthedifferentmeasuresandthevaluesthereofisalsoconducted.Theresultsoftheseanalysiswillinformaneconometricmodel on the costs and utilities of healthcare technologies and interventions for children andadolescents with disabilities. The results further question the generalisability of valuationmethodsacrosspopulationgroups,diseasesandsettings.


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Outcomes and associated factors of integrated community case management of childhood illnesses in dawro zone, South West Ethiopia

*Tesfaye DagneWeldemarium, ** Sisay Dejene, *Waju Beyene: *Jimma University, ** Dawuro HealthOffice

Background:After its scaleup inMarch2011 integratedcommunity casemanagement (ICCM)wasprovidedinabout86%nationalgeographiccoverage;88%healthextensionworkers(HEWs)weretrained;andcareseekingforunder-fivechildrenathealthpostswas increased.However,under-five childrenhealthoutcomes followingmanagementof commonchildhood illnessesbyHEWsusingICCMprotocolanditsassociatedfactorswerenotstudiedyet.

Objective: The aim of this studywas to assess outcomes and associated factors of integratedcommunitycasemanagementofchildhoodillnessesserviceinDawrozone,southwestEthiopia,2017

Methods:Communitybasedcross-sectionalstudydesignwasemployedinthisstudy.ThestudywasconductedfromMarch15toApril12,2017inDawrozone,southwestEthiopia.Caregiversof791randomlyselectedunder-fivechildrentreatedbyusingICCMprotocolfromJuly2016toJanuary2017insampledkebeleswerestudyparticipants.Multinomiallogisticregressionanalysiswasused to fitamodeland identifyvariablesassociatedwithoutcomesof ICCM.Summaryoftheresultwaspresenteddescriptivelybyfrequencytables,graphs,andchartsandanalyticallybyp-value,adjustedoddsratio,andconfidenceinterval.

Result: Sevenhundredninetyone caregiverswereparticipated in this study yielding about98percent response rate. Among the 791 under-five year childrenmanaged by health extensionworkersforcommonchildhoodillnesses,705,58,and28werecured,encounteredcomplication,anddiedrespectively.Whencuredcasescomparedtoworsencases,theindependentvariables;caregiver’seducationalstatus,householdwealth,ageofthechild,distancefromhometohealthpost, caregiver’s knowledge of childhood danger signs, and harmful traditional practicesweresignificant predictors of outcomes of children managed by HEWs through ICCM program. Allaforementioned variables except harmful traditional practices were significantly associatedwhencuredcasescomparedtothatofdeadcases.

Conclusion: This study found that most of the under-five children improved following themanagementofcommonchildhood illnessesbyhealthextensionworkers.Attentionshouldbegiven to infants, children far from health posts, teaching caregivers about childhood dangersigns,eliminatingharmfultraditionalpracticesonunder-fivechildrentogainbetterchildhealthoutcomes.

Using Intervention Mapping to Design and Implement Quality Improvement Strategies Towards Elimination of Lymphatic Filariasis in Northern Ghana.

AlfredKwesiManyeh1,2,4*;FrankBaiden4;LatifatIbisomi1;TobiasChirwa1;RamaswamyRohit1,31Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand,Parktown,Johannesburg,SouthAfrica.2DodowaHealthResearchCentre,DodowaGhana.3PublicHealth Leadership Program,Gillings School ofGlobal PublicHealth,University ofNorth Carolina,4107,McGavran-GreenbergHall,ChapelHill,NC,USA.4EnsignCollegeofPublicHealth,DivisionofEpidemiologyandBiostatistics,Ghana.


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TheGlobalStrategytoEliminateLymphaticFiliariasis(GFELF)throughMassDrugAdministration(MDA) has been implemented in Ghana since the year 2000 and transmission has beeninterruptedin76outof98endemicdistricts.ToimprovetheMDAintheremainingdistrictswithmicrofilaria(MF)prevalenceabovethe1%thresholdneedforthe interruptionoftransmission,there is theneedto identifyand implementappropriatequality improvement (QI) strategy fortheeliminationofthediseaseasapublichealthprobleminGhana.

Due to thecomplexitiesassociatedwith implementingevidencebasedprograms (EBP) suchasthe lymphatic filariasis MDA and variability in their context, an initial assessment to identifyimplementationbottlenecksassociatedwith the implementationof lymphatic filariasisMDA inBole District of Ghana was conducted. A context specific QI strategy was designed andoperationalizedusinginterventionmapping(IM)strategyintermsofsevendomains:actor,theaction,action targets, temporality,dose, implementationoutcomesaddressed,and theoreticaljustification.

This article describes the processes and the methods used in selecting the context specifictailored QI strategies to address identified bottleneck within an existing evidence basedinterventionforeliminationoflymphaticfilariasisinBoleDistrictofGhana.

Keywords: Lymphatic Filariasis, Quality Improvement,Mass Drug Administration, InterventionMapping,Ghana.

Parallel Session 8-3 Priority setting and economic evaluation

Primary health care delivery in post-apartheid South Africa: Exploring the equity-enhancing contributions of the public sector

KehindeO.OmotosoSteveKoch,DepartmentofEconomics,UniversityofPretoriaBackground:Priorto1994,SouthAfrica’shealthsystemwasdividedalongraciallines.Post1994,the South African health systemwas developed into a two-tiered systemdivided along socio-economic lines. Since the emergence of democracy in the last two decades in South Africa,considerable effort has gone into redressing the socio-economic and health care inequalities,which characterised the Apartheid regime. Specifically, the South African government hasembarked on a variety of policies and reforms to reverse the discriminatory practices thatpervadedallaspectsoflifebefore1994.Policyinterventionshavetargetedreductionsinsocio-economicinequalitiesinvariouscapacities,and,byextension,thesepolicieshavealsoappliedtothe health care system: fiscal redistribution targeted at health, education, social protectionsectors;abolitionofuser feesat theprimaryhealthcare(PHC) level in1994;extensionofPHCpolicy to all users in relatively poorer households in 1996; and ongoing discussions related touniversalhealthcarecoveragethroughayet-to-be-fully-implementednationalhealthinsurance(NHI),amongothers.

Aimandobjectives:Thisstudysetsouttoexploretheindirectcontributionsofthevariouspublicpoliciesandreformstargetedatreducinginequityinhealthcareaccessovertheseconddecadeof post-apartheid South Africa. Specifically, the contributionswere linked to changes in socialfactorswhichareoftentargetsofpolicydecisions.

Methods:Datacomefrominformationcollectedonsocialdeterminantsofhealth(SDH)andonpublicversusprivatehealthcareaccessinthe2004and2014questionnairesoftheSouthAfrican


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General Household Surveys (GHSs), nationally representative surveys. A decomposition ofchangeinaconcentrationindexmethodwasemployedtounravelthecontributionsofthepublicsectortoequityinaccesstohealthcareoverthestudiedtimeperiod.

Key findings:Overall, theresultsshowan improvement inaccesstohealthcareoverthepost-apartheidperiod,especiallyforthepreviouslydisadvantagedpopulationgroups;withawideningpreference for private health care in the event of illness. However, differences in rural/urbanlocationandeducationalattainmentcontributelargelytoinequalitiesinaccesstohealthcare.

Mainconclusions:Whileprogresshasbeenmadeinimprovingaccesstoprimaryhealthcareinpost-apartheidSouthAfrica,policiestailoredtowardsincreasingaccessinruralareasandamongtheuneducatedcouldfurtherprovebeneficialinreducinginequalitiesofaccesstohealthcare.

Are Community Health Workers the missing link in improving capacity of the health systems preventive arm?

MUTEBIALOYSIUS,MakerereUniversitySchoolofPublicHealth,Uganda

BackgroundMostdeathscanbeaverted throughsimpleevidence-based interventions suchasthe use of CommunityHealthWorkers (CHWs), also known as village health teams inUganda(VHTs). However, the CHW strategy still faces implementation challenges regarding trainingpackages, supervision, and motivation. The WHO advocates for the use of CHWs to expandhealth services coverage, as one of themethod to tackle health workers shortagesmostly indevelopingcountries.

Methods CHWs were invited to share their perspectives and experiences on their role:Qualitativeinterviews(In-depthinterviews)with15CHWsfromthreedistrictsi.e.Kamuli,PallisaandKibukuexplored theirmotivations,aswell as thechallenges theyencountered.EachCHWwas also interviewed independently,which gave insight into thepractical day-to-day activitiesthattheyengagein.

Results CHWsmentioned that the keymotivation for taking on their rolewas elevating theirstatus in their community, but themain barrierwas lack of confidence resulting from lack ofappropriate training and supervision. In-depth interviews revealed that CHWs, contrary toliterature, are the ‘front line’ healthworkers regarding basic health care,which extends to allpreventivediseases.ComplexhealthissuesthatwereaddressedbyCHWsincludedprovisionofcare for medication defaulters, sensitisation on antenatal care; malaria; bothhousehold/personalhygiene;andbeing‘firstresponderstocommunityemergencies.

ConclusionsWithdecentralizationleveloneofthehealthcaresystemsisnowthevillageorLC1whereCHWsarefound.CHWsarekeyhealthsupportstaffwhoshoulderasignificantburdenofcareatcommunitylevel.Inpractice,CHWsprovidemorethanbasiccareespeciallytoHIV/AIDSand TB patients. CHWs are very crucial in expanding health coverage mostly in rural andunderservedcommunities.Thishasreducedtheburdenonhealthfacilitystaff.However,lackoftraining and other materials that CHWs lack, make them feel ill-equipped to deal with thechallengesthattheyencounteronadailybasis.IfthesegapsareaddressedthenCHWswouldbethemagicbullettowardsimprovedhouseholdhealthcare.

Keywords:Communityhealthworkers,healthservices,coverage

Intra-urban inequality, a new emerging child health peril in Africa: the case of South Africa

OlufunkeA.Alaba:HealthEconomicsUnit,UniversityofCapeTown,CapeTown,SouthAfrica


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IntroductionTherearemoreinfluencesonchildhealthandmortalityinSouthAfricathanwhatisrevealed simply by looking at averages, aggregate economic growth and the seeming prioritythathasbeengiventosocialdevelopmentandchildwelfareespeciallywiththerapidlygrowingurbancities.Inequalitiesbecomeapparentwheneffortsaremadetodisaggregatethepicture.

Although,therural-urbandisparitiesinchildmalnutritionamongsocioeconomicgroupsistoberecognized, intra-urbandifferential is fast becoming a peril to child healthoutcomes includingchildmalnutritioninsub-SharanAfrica.Childhoodmalnutritionremainsaglobalchallenge.Giventhatmalnutrition is an underlying cause of over 50% of under-five deaths, it is clear that theaccomplishmentofSustainabledevelopmentgoals (SDGs) requireactiondirectedat improvingthenutritionalstatusofvulnerablechildren.

Objective Thus, this study empirically investigates the understanding of the role of the urbanenvironment in shaping inclusivity of children to basic need like healthcare and improvednutritionwithinthesocialdeterminants framework inSouthAfricancities.Thestudyexaminesdifferent features of the urban environment, especially income inequality within the urbanenvironmentthatmay influencechildnutritionaloutcomesbydevelopmentalstages(Infancy:0to18monthsandearly childhood:18months to60months) aswell as thepathways throughwhich itoccurs inorder tomeetSDGtargets10.2and11.7amongstothers.Additional factorssuchasthenatureofthehomeenvironmentandcapabilitiesoftheparentsareinvestigated.

MethodologyandDataThestudypopulationforthisempiricalinvestigationiswasting,stuntingand underweight within under-five children from the South Africa National Income DynamicsStudy (NIDS) 2012matchedwith intra-cities income inequalitymeasures from the 2011 SouthAfricancensus.NIDSisdesignedtocollecthouseholddatathatcanbeusedtoevaluatevariousaspects of householdwelfare and behaviour and to evaluate the effectiveness of governmentpoliciesonthelivingconditionsofthenation.Thestudyappliesamulti-levelmodellingapproachwithinasocialdeterminantsframework.

ConclusionResultsshowedthatchildrenfromthepoorest10percentofhouseholdshavehigherratesofunderweightandstuntingcomparedtotherichest10percent.Thisstudydidnotonlyprovide a picture of the current state of child wellbeing in South Africa, it also consideredpossible effects of wider contextual (such as neighbourhood) influences on childhoodmalnutrition.

Economic Fluctuations and Child Mortality: How Well Children’s Health Needs are Met in Nigeria.

AbdulganiyuSalami,LafiaFederalUniversityLafia

This study investigated the effect of economic fluctuations on child mortality rates, usingNigerian time series data. Using ARDL Bound test and Fully-modified ordinary least squareregression imbeddedwithdistributed lagofGDPper capita, itwas found thatGDPper capitasignificantly influence neonatal, under-5 and infant mortalities negatively. It is thereforerecommended thatpolicymakersput inplacepolicies thatwill improve childhealth,GDPpercapita,generalproductivityandensureoveralleconomicbuoyancy.

Keywords:childmortality,GDPpercapita,policymakers


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Identifying the challenges in Delivering the Essential Health Care Package in Eswatini

*DianaKizza,**VelephiOkello:*MbabaneClintonHealthAccessInitiative,**MinistryofHealth,Eswatini

The egalitarian goal of Universal Health coverage (UHC) by 2030, to provide health serviceswithoutfinancialhardshiptoeverymemberofthepopulation;garnerswellwiththemonarchistsystemoftheKingdomofEswatini,thataspirestoattainsocialequality.

ThegovernmenthascommittedtoachievingUniversalHealthCoverage(UHC),asprioritized intheNationalHealth Strategy (NHSSP II 2017–2020) and theNationalHealth FinancingPolicy.The Essential Health Care Package (EHCP) defines the set of services to be provided freely ateach level of the health system to reduce the disease burden and provide for the poor andvulnerable. Ministry of Health worked with stakeholders to develop a systematic practicalapproach to operationalize the EHCP and navigate from the decision to deliver and on-the-groundimplementation.

To assess the ability of facilities to deliver the EHCP, government conducted facility servicereadiness assessments, and extensive resource availability assessments in 10 clinics and twohospitalstounderstandtheinputgapspreventingEHCPservicedelivery.Theserevealedgapsinavailability of General Service Readiness commodities, including essentialmedicines and basicequipment items such as infection prevention, adult/pediatric examination, and point of carediagnostics.Given the identified challenges in resourcegapsand inefficiencies, theMinistryofHealthadoptedasystematicapproachtodiagnoseandaddressimplementationchallengesfroma facilities perspective. Each facility conducted fish-bone analysis and root cause analysis toidentify the causal bottlenecks in the supply chainofGeneral ServiceReadinessCommodities.Thisadditionalanalysisprovidedarangeofsystemicsupplychainandbudgetingissues.

Toaddresstheseissues,qualityimprovementtechniqueshavebeenadoptedtofillthegapsanddriveefficiencies.TheMinistryworkedto identifyservicedeliveryreformswhichcouldhelpusservicedeliverygapsthroughinnovativeformsofservicedelivery.

Thekeylessonwasthatresourceavailabilityassessmentoutputwasnotdirectlyactionablefroma health systems strengthening perspective. Follow-up processing mapping was required tounderstandthesystemicrootcausespreventingresourcesfrombeingavailabletothefront-lineclinician.Furtherfollow-upworkwasrequiredtoconnectresourcestheirrespectivebudgetsandsupplychainsinidentifyingsolutionstosolvethebottlenecks.Afterthisconsultationprocess,acomprehensive standardResourceMatrixof theessential resource inputsnecessary todelivertheserviceswasdeveloped.

Implementing Health Financing Reforms in Nigeria: A case study on the Basic Healthcare Provision Fund (BHCPF)

NnekaOrjiAbujaFederalMinistryofHealth,BenjaminUzochukwuUniversityofNigeria

BackgroundNigeria’shealthsystemisstructuredlikeherconstitutionalgovernancesystemwithdiverse stakeholders that showcase mixed interests. Considering these complexities, policymakers,healthcareprovidersandmajorstakeholdershavebeensaddledwiththechallengeofimproving the performance of the health system. A number of health reforms have beenimplemented, but these efforts and investments have failed to demonstrate commensuratereturnsoninvestments.Despitetheseinvestments,Nigeriahasexperiencedincrementalout-of-pockethealthexpenditureandasatthelastestimatein2016,out-of-pockethouseholdspendingwas very high at an average of 69.7% of total health expenditure compared to the global


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benchmarkof30-40%.Torespondtothesesystemicchallenges,theNationalHealthAct(NHAct)wasenacted in2014.TheActprovides foraBHCPF tobeused for the strategicpurchaseofaBasicMinimumPackageofHealth Services; it furtherprescribes a coordination framework fortheNationalHealthSystem.

AimToassessandanalyzethefeasibilityofstrategiesforimplementingtheBHCPF.

Objectives To identify and analyze the main factors impacting on the implementation of theBHCPF;ProposerecommendationstofasttracktheimplementationoftheBHCPF.

Method Key respondents were interviewed using a semi structured tool. Respondents werepurposivelyselectedtoreflectthedifferentstakeholdersateachlevelofimplementationoftheBHCPF- (FMOH, NPHCDA, NHIS, Federal Ministry of Finance,Ministry of Budget and NationalPlanning),Mediagroup,Stategovernmentinstitutions(SMOH,SPHCDA,SSHIS,StateMinistryofFinance,MinistryofLocalGovernment); LocalGovernmentHealthAuthorities,Healthworkers,keyofficersof the facilitydevelopment committees,DevelopmentPartners andDonors, CSOs,andCommunitymembers.

Key findings Findings revealhealth systems issues thatpredate theenactmentof theAct; thestrategiesdevelopedtorespondtothese issuesseemfit forpurposebutthecurrentapproachforoperationalizingthesestrategieshasratherthancontributetorevampingthesystem,thrownupthornypolicy issuesandpolitical interferences inthehealthsystem. Clear interpretationofthe provisions of the Act for actors in the systemmay be very valuable. Political interferencesomewhat contributed to the delays and mistrusts in financing the BHCPF using donor andgovernmentresources.

Conclusion The key challenges that contributed to the delays and non-implementation of theBHCPF should be addressed. The identified challenges include, issues of transparency, poorunderstanding of the mandates of key officers, political interference, and non-release ofgovernmentcommitmenttotheBHCPF.

Parallel Session 8-4 Human Resources for Health – innovative approaches

The midwives service scheme: a qualitative comparison of contextual determinants of the performance of two states in central Nigeria

*Arnold Okpani, **Seye Abimbola: *National Primary Health Care Development Agency, University ofSydney,Australia

BackgroundThefederalgovernmentofNigeriastartedtheMidwivesServiceSchemein2009toaddressthescarcityofskilledhealthworkersinruralcommunitiesbytemporarilyredistributingmidwivesfromurbantoruralcommunities.Theschemewasdesignedasacollaborationamongfederal, state and local governments. Six years on, this study examines the contextual factorsthat account for the differences in performance of the scheme in Benue and Kogi, twocontiguousstatesincentralNigeria.

Methods We obtained qualitative data through 14 in-depth interviews and 2 focus groupdiscussions: 14 government officials at the federal, state and local government levels wereinterviewedtoexploretheirperceptionsonthedesign,implementationandsustainabilityofthe


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Midwives Service Scheme. In addition, mothers in rural communities participated in 2 focusgroupdiscussions(oneineachstate)toelicittheirviewsonMidwivesServiceSchemeservices.Thequalitativedatawereanalysedforthemes.

ResultsTheinabilityofthefederalgovernmenttosubstantiallyinfluencethehealthcareagendaofsub-nationalgovernmentswasasignificantimpedimenttotheachievementoftheobjectivesoftheMidwivesServiceScheme.Participantsidentifieddifferencesingovernmentprioritisationof primary health care between Benue and Kogi as relevant to maternal and child healthoutcomes in those states: Kogiwas farmore supportive of theMidwives Service Scheme andprimaryhealthcaremorebroadly.HighuserfeesinBenuewasasignificantbarriertotheuptakeofavailablematernalandchildhealthservices.

ConclusionDifferential levelsofpoliticalsupportandprioritisation,alongsidefinancialbarriers,contribute substantially to the uptake ofmaternal and child health services. For collaborativehealthsectorstrategiestogainsufficienttraction,wherefederatingunitsdeterminetheirhealthcare priorities, they must be accompanied by strong and enforceable commitment by sub-nationalgovernments.

Analysis of Factors Affecting Leadership Training Transfer Within a Health System Context: Learning from the Experience of Kenya’s Healthcare Leaders.

T.Chelagat1,G.Kokwaro1,J.Onyango1,J.Rice1StrathmoreUniversityBusinessSchool/InstituteofHealthcareManagementKnowledge transfer in organisations is evidently being recognized as a key determinant oforganisational competitiveness. Research evidence confirms that the conditions under whichknowledge is transferred has great influence on organisational performance improvement.However,eventhoughorganisationsarerealizingpositiveimpactofknowledgeonperformance,drivers and barriers for successful knowledge transfer in different scopes and contexts areunder-represented.Thestudysoughttobridgethecurrentgapbetweentheoreticalperceptionsonknowledge transferand the leadership reality today.This isachieved through identificationand analysis of factors affecting leadership knowledge transfer in healthcare organizations inKenya.Mixedmethodsdesignwithoutarandomassignmentwasadopted,toprovideevidenceson effective strategies for transferring knowledge as well as its facilitators and barriers. Thestudyparticipantswere39StrathmoreBusinessSchool,healthcareleadership,managementandgovernance(LMG)programalumni.Thegroupweretrainedbetweentheyear(2011-2016)from19countiesinKenya,fromthepublic,privateandfaith-basedhealthsector.Theresultsindicatethat transfermechanisms relatedpositivelywith theextent towhichmanagers supportedandreinforcedtheuseoflearningon-the-job(P=0.021);theextensiontowhichtrainingisdesignedtogivetraineesabilitytotransferlearningtojobapplicationandtraininginstructionsmatchthejob requirement (P=0.027); and the opportunity to use the learning at work environment(P=0.022).Theresultsprovideevidencethatabilityscales(transferdesignandopportunitytouselearning) andwork environment scale (supervisors support to use learning) plays amediatingrole between the training learning and performance improvement, in a healthcare leadershipcontext. The study concludeswith recommendations that can be integrated successfully andinform future programs design and partnerships within the health system healthcareorganisations towards maximization of knowledge transfer process from classroom setting toworkenvironment.

Keywords: Healthcare performance, learning transfer system inventory scale, team-basedcoaching,prioritychallengeproject.


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The short-term and long-term cost-effectiveness of an augmented exercise referral scheme: A within-trial analysis and beyond-trial modelling

AnokyeN1,IngramW,TaylorRS,TaylorATrialSteeringCommittee1HealthEconomicsResearchGroup,DepartmentofClinicalSciences,BrunelUniversityLondon.

Improvingphysicalactivityisawidely-statedpolicyaimfromnationaltointernationallevel.Itistherefore important to establish which approaches are effective and efficient at encouraginginactive individuals to become active. This would inform public health policy and practice.However,thereispaucityofevidenceoneconomicevaluationofphysicalactivityinterventionsparticularlyinlowandmiddleincomecountries.Buildingonthemethodsofacost-effectivenessanalysis of an augmented exercise referral scheme (ERS), the presentation providesrecommendationsforthehealtheconomicsresearchagendainAfrica.

A short and long term cost-effectiveness analysis of an augmented exercise referral schemealongsideatrialwasundertakenusinghealthcareprovider,personalsocialservices,andpatientperspective. A multicentre parallel two group randomised controlled trial with 1:1 individualallocation tousualERSalone (control)oraugmentedexercise referral schemewithweb-basedbehavioural support based on the LifeGuide platform. Participants were inactive people withobesity,diabetes,hypertension,osteoarthritisorhistoryofdepression,referredtoanERSfromprimarycareinUK.

Theanalysesweretwo-fold–shortterm(within-trial)cost-effectivenessanalysis(frombaselineto 12 months post randomisation) and long term cost-effectiveness analysis (beyond-trialmodelling of long term expectations for cost-effectiveness), for augmented exercise referralscheme using web-based behavioural support against standard exercise referral scheme.Deterministicandprobabilisticsensitivityanalysesevaluateuncertainty.

ThemainoutcomeoftheeconomicanalysisisanincrementalcostperQuality-AdjustedLife-Year(QALY-basedonEQ5D5L).Theshorttermcost-effectivenessanalysisusesresourceusedatafordevelopment of training for LifeGuide coach, and technician; web and exercise support (e.g.duration and frequency) provided by technician; LifeGuide coach and health professionalsrespectively; provision and running of the exercise sessions at leisure centres; and health andpersonal social service use. The long-term cost effectiveness is based on an existing policyrelevantdecisionanalyticalmodel (has informed3publichealthguidelines inUK).Theanalysisaccountfortheimpactofphysicalactivityonlifetimeriskofdevelopingcoronaryheartdisease,stroke, and type II diabetes. The discussion highlights the considerations for adapting theeconomicmodeltoanalysethevalueformoneyofphysicalactivityprogrammesinAfrica.

Frontline Health Worker Performance on MNCH Care at the PHC Levels in Nigeria

GodwinUnumeri1a,EkechiOkereke1,IbrahimSuleiman1aGodwinUnumeri,1PopulationCouncil

Background: Facility-based evidence indicate that strengthening frontline health workers(FLHWs) at the primary health care (PHC) levels reduce the incidence ofmaternal and infanthealthmortalitywhen thepersonal,organisational andcommunity factorsare supportiveasasurveyinBauchiandCrossRiverStates(CRS)ofNigeriaestablished.


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AimsandObjectives andMethods:Toestablisharelationshipbetweenthecontextual factorsthatpromoteeffective servicedeliverybyFLHWsand reduction in facility-basedmaternal andinfantmortalityinNigeria.

Method:Thecross-sectionalstudywasconductedinNovember(6-13,2016)toobtaindatafromFLHWswhohadworkedatthePHClevels12monthsprior,in2localgovernmentareas(LGAs)ineachState.

Results: Personal FLHWs contentment (Bauchi 100%; CRS 100%); motivation to serve (Bauchi95.9%;CRS92%); jobeffectiveness (Bauchi95.9%;93.9%)andopportunitytouseskills (Bauchi95.9%; CRS 98.5%) were associated with performanceMNCH roles. Other correlates includedorganizational factors like keeping the health facility opened and previous training forMNCHcare (CRS 90%; Bauchi 60%). Village/ward support for disseminating knowledge on MNCHprevention/treatmenttoFLHWs/facility(CHEWs79.2%;JCHEWs80.9%);communitymobilization(CHEWs 84.5%; JCHEWs 83.0%); record keeping support (CHEWs 71.7%; JCHEWs 68.1) andassistanceduringtraining(CHEWs71.7%;JCHEWs85.7%)werecommunity interventionslisted.PersonalfactorsthatinhibitedFLHWwerelowknowledgeonANCcare/counseling,dangersignsandsymptoms/complicationsofpregnancyandmanagementofdelivery/childhealth(lessthan10% in Bauchi and CRS). Reported organizational inhibitors were lack of stethoscope (Bauchi47.8%; CRS 46.7%); thermometer for CHEWs (Bauchi 31.9%; CRS 43.3%) and JCHEWs (Bauchi54.5%;CRS20.0%);weighingscaleforCHEWs(Bauchi43.5%;CRS36.0%);JCHEWs(Bauchi54.5%;CRS56.7%)andinfantscale(BauchiandCRS40%).

MainConclusions:FacilitieswhereFLHWsprovidedMNCHcareatPHClevelsinanenvironmentwith favourablepersonal, organizational and community factorsmaternal and infantmortalitywere significantly low. Also, carefully planned monitoring, supportive supervision, traineefeedbackandimplementedrecommendationssimilarlyenhancedtheperformanceofFLHWsatthePHClevelsinNigeria.

Health facility-related determinants of choice for health care provider: lessons towards achieving the goals of universal health coverage in Uganda

PerezN.Ochanda¹†,StephenOkoboi¹¹InfectiousDiseasesInstitute,DepartmentofResearch,P.O.Box22418,Kampala¹InfectiousDiseasesInstitute,DepartmentofResearch,P.O.Box22418,Kampala BACKGROUND: Thenexus betweenPrimaryHealth Care (PHC) andUniversalHealth Coverage(UHC) continues to dominate health policy discussions globally especially for low andmiddle-incomeeconomies.ThereisgrowingconsensusthatthemosteffectivewaytodeliverUHCisbyachievingamoreefficientPHCsystem.Uganda’sHouseholdOut-of-pocketexpenditureaccountsfor over 40% of the total health expenditure with over 50% of these expenditures made toprivatelyownedfacilities.Thusthemotivationforthisstudy.

OBJECTIVES:Aimed toexaminehealth facility-relateddeterminantsof choice forpublichealthfacilitiesrelativetoprivatehealthfacilitiesinUganda.Specifically,weexaminehowfacility-basedfactors such as; inpatients beds, laboratory, cost of treatment, availability of medicine,electricity,staffmeals,determinechoiceofhealthcareprovider.

METHODS:We borrow theWHOHealth financing conceptual frameworkwhich identifies keyfunctions of efficient health systems like; resourcemobilization, financing and investment forbetter health services.AUnivariate logistic regressionwas applied. Community level datawasextracted from the recent wave of Uganda National Panel Survey in 2016. Choice of facility(PublicorPrivate)wasthebinaryoutcomevariablewhileinpatientbeds,functioninglaboratory,


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costoftreatment,electricitywerekeyexplanatoryvariablescontrollingforothercovariateslike;availabilityofmedicine,waitingtime.

RESULTS: The study included 300 eligible community level respondents. Private facilities outperformedpublicfacilitieswith(29%,29%&88%)providingstaffmeals,havinglongwaitingtimeandafunctioninglaboratorycomparedto(2%,50%&68%)ofpublicfacilitiesrespectively.Moreprivatefacilities(53%)werereportedexpensivecomparedtoamere4%ofpublicfacilities.Oddsratioforavailabilityofinpatientbeds(1.407)andexpensivetreatment(0.008)werestatisticallysignificant with P<0.05 and P<0.01 respectively. The likelihood of choosing a public facilityreduceswith increase in thecostof treatmentand increaseswithavailabilityofmoremedicalequipmentsuchasinpatientbeds.

CONCLUSION: We conclude that people may not use public facility if they perceive it asexpensive. The bivariate analysis indicates better quality in private health facility relative topublicfacilitiesintermsof;waitingtime,availabilityofdrugs&supplies,functioninglaboratory.This implies that high household OOP expenditure in Uganda may be due to individualpreferencetopaymoreinprivatehealthfacilitiesexpectingbetterqualityofservice.Thus,moreefforts towards improving quality in public health facilities form an integral part towardsachievingequitablePHCforallandconsequentlyUHC.

Patterns of incentives for frontline health workers at primary healthcare (PHC) level in Nigeria: implications for health workers’ performance.

EkechiOkereke1,BelloMohammed2,AkinwumiAkinola1,GeorgeEluwa11PopulationCouncilNigeria,2WorldHealthOrganizationNigeria Background A properly motivated health workforce is a prerequisite for effective maternal,newbornandchildhealth(MNCH)servicedelivery,butfrontlinehealthworkers(FLHWs)maybereluctanttoworkinruralprimaryhealthcaresettings.Factorsthatinfluencethemotivationandretentionofhealthcareworkersindevelopingcountrieshavenotbeenexhaustivelyresearchedbut providing incentives to FLHWs could be a viable policy option to improve themotivation,retentionandperformanceofhealthworkers,especiallyinruralsettings.

Aim:ThisstudyexploredpatternsofincentivesreceivedbyFLHWsinruralcommunitiesanditsimplicationsforjobperformanceatprimaryhealthcarelevelinNigeria.

Methods The study adopted a cross-sectional quantitative design in two States in Nigeria.Structured interviewswere conductedwith 114 FLHWs using Personal Digital Assistants. Dataanalysis was done using SPSS software. Descriptive analysis was carried out using percentagefrequency distribution tables. Bivariate analysis explored relationships between the level ofsatisfactionwithincentivesreceivedbyFLHWsandtheirperformancewithinprimaryhealthcarerural settings. Multivariate regression analysis was done to ascertain the extent of therelationship between satisfaction of frontline health workers with the incentives which theyreceiveandtheirperformance.

Key Findings Results show that half (51.8%) of FLHWs received incentives for theirwork. TheState government provided the least (11.7%) incentiveswhile host communities and ‘not-for-profit organizations’ provided 26.7% and 18.3% of incentives respectively. Money-for-referral(3.3%)wastheleastutilizedincentivewhilepaymentofruralpostingallowance(66.1%)wasthemostutilizedformofincentive.Bivariateanalysisshowsastatisticallysignificantrelationship(p=0.012) between satisfaction with incentives received by FLHWs and their health care servicedeliveryperformanceatprimaryhealthcare level.Results fromunadjustedregression indicatesthathealthworkerswhowere satisfiedwith incentiveswere2.8 timesmore likely toperform


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betterthanthosewhowereunsatisfiedwith incentivesreceived. (P=0.013,C.I=1.3-6.3).Whenother predictors were controlled for within the multivariate regression model, those whoreceivedincentivesandweresatisfiedwiththeincentiveswere3.3timesmorelikelytoperformbetterthanthosewhowereunsatisfied(P=0.009,C.I=1.3-8.2).

Main Conclusions Governments at all levels should provide incentives to frontline healthworkersworking inruralcommunitiesto improve jobsatisfactionandperformance.Structuredperformance-basedincentivemechanismsarehighlyrecommendedatprimaryhealthcare levelwhichshouldleadtobettermaternal,newbornandchildhealthoutcomesespeciallyacrossthedevelopingworld,includingwithinsub-SaharanAfrica.

Factors enabling and disenabling the services provided by community health workers: Case study of two health districts in South Africa

*Hlologelo Malatji, *Jane Goudge, **Julia De Kadt: Centre for Health Policy, School of Public Health,UniversityoftheWitwatersrand,GautengCityRegionObservatory

Background As part of strengthening primary health care, the South African government hasintroduced ward-based outreach teams to work in under-served communities. In thesecommunities, community health workers (CHWs) give health talks and refer health cases toprimary health facilities for care. However, available literature highlight poor supervision,shortageofequipmentsand limitedcommunity linkassomeofthechallengesconfrontingthiscadreofworkersinthecommunities.

As the SA has started implementing the NHI, these challenges need to be corrected becauseCHWs formpartof theworkforce thatwill continue to linkneedypeople tohealthcareundertheNHI.

AimThisstudyaimedtoexploretheexperiences,successesandchallengesofcommunityhealthworkersintwohealthdistrictsinSouthAfricainthecontextoftheNHI.

MethodsWeemployedqualitativeapproaches to recruitand interviewstudyparticipantswhocomprised of, facility managers, CHWs and their team leaders and community leaders wereinterviewedtogather insightsofexperiences, successesandchallenges that theyencounter inprovidingprimaryhealthcareservicesatcommunitylevel.

FindingsandconclusionsCHWsserveasthemainlinkbetweenvulnerablemembersofsocietyandthehealthcaresystem.Despitethis,wefoundoutthatCHWsfaceanumberofchallengesincluding lackofworking tools, insufficient supervisionandnon-integrationof their services tothehealthcaresystem.This limitedtheeffortstheyput inplacetohelpthosesufferingat thecommunity.

We argue that integration of CHWs into the main health care system through provision ofnecessary tools and appreciation of theirworkwill not only boost theirmorale in serving thecommunitybutimprovetheaccesstocareforthevulnerable.

Keywords:communityhealthworkers,primaryhealthcareservices,experiences,challenges

Going operational with health systems governance: supervision and incentives to health workers for higher quality health care in public health facilities in Tanzania

IgorFrancetic,PhDstudentinEpidemiologyandPublicHealth,SwissTPH(Basel,Switzerland)


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Background Health systems governance is increasingly high in the global health agenda.However,most analyses focus on conceptual frameworks rather thanoperational aspects andimpactsonhealthservicedelivery.Threenotablehealthsystemsgovernance interventionsaretop-down supervision, bottom-up community supervision and incentive policies for healthworkers. Some evidence is available about the individual effectiveness of these tools towardshigher quality of healthcare in Tanzania. Yet, little is known about their combined impact aspolicytoolsavailabletolocalgovernmentauthorities.Thisstudyanalyzedquantitativelythejointeffectoftop-downandbottom-upsupervisionaswellasincentivepoliciesonproxiesofqualityofcare.

Methods The study employedmultilevel logistic regression techniques on a dataset from theDemographicHealthSurvey(DHS),the2014/15waveoftheServiceProvisionAssessment(SPA)survey, focusing on a representative sample of Tanzanian health facilities. The data includedprocessofcaremeasuresfrompatientvisitobservationsandexitinterviews,infrastructuralandmanagerial data related to the health facility from an inventory survey as well as specificinformation about healthcare providers from health workers interviews. From the availabledatasetweobtainedproxyindicatorsforqualityofcare, intensityofsupervisionandincentivesavailabletohealthworkers.TheproxymeasuresofqualityofcarearecompliancetoIntegratedManagementofChildhoodIllness(IMCI)guidelinesontheonehand,andpatientsatisfactionontheotherhand.

Results and discussion Three main results emerge from the study, contributing to fill theevidencegapandbetteraddresspoliciesfocusedonimprovingtheproductivityofmedicalstaffand consequently patients’ satisfaction. First, top-down supervision is not associated withincreasedquality of care. The existing supervision arrangementsmaybe suboptimal,with lowsupervisionintensityand/orlackofconstructivefeedbackfromsupervisors.Second,bottom-upsupervisionthatengagesthecommunityfavorshigherpatientsatisfaction.Thecommunitymaybemoreawareoftheeffortputinplacebyhealthworkersintheirdailyactivities.Atthesametime,healthpersonneladdressbettertheneedsofthecommunity,withdirectreturnsintermsofsatisfactionevenwithoutqualityimprovements.Third,theprovisionofsubsidizedhousingtohealthworkersisassociatedwithbothhigherhealthcarequalityandhigherpatientsatisfaction.Movingawayfromtheirhometownstoaddressshortageofhumanresources inotherpartsofthecountryandwithmodestsalaries,livingarrangementsseemtobeanimportantmotivationalfactorforTanzanianhealthworkers.

Parallel Session 8-5 Access to health care services

Analysis of the determinants of health care demand choice in Ivory Coast

DrRomualdGUEDE(1);PrAugusteK.KOUAKOU(2);DrAppolinaireYAPI(3)(1)UniversityofJeanLorougnonGuede(Daloa,IvoryCoast) (2)UniversityofJeanLorougnonGuede(UJLoG-Daloa) (3)NationalInstituteofPublicHealth-Abidjan

Introduction:At theendof themilitary-political crisis in2011, IvoryCoastgavepriority to thehealth sector to care for the most vulnerable. However, despite the efforts made, manychallengestoaccesscareexist,particularlyinhealthfacilities(RASS2016).Thegeographicaland


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financial accessibility of poor populations is a major concern. This study aims to investigate,basedonindividualdata,thefactorsthatexplainthedemandforcareinCôted'Ivoire.

Variablesandmethodologies:Intheliterature,variablesarelikelytoinfluencetheuseofcare:

# socio-economicvariables:income,healthinsurancepolicy;# socio-demographicvariables:levelofeducation,age,sex,placeofresidence,household

size;# costvariables:benefitcosts,drugs,transportation,hospitalizations;# accessibilityvariables:geographicalaccessibility,regularityofaccesstoahealthworker.

A Logit-binary is used on data from the Household Standard of Living Survey (ENV 2015)conductedby theNational Statistics Institute (INS)andwe retain1108observations (455menand653women).

Results:Theuseofcareissignificantlyinfluencedbythefollowingfactors:

→ Remotenessexplains10.08%oftheformaluseofcare;→ Thelackofhealthpersonnelinfluencesfor8.00%;→ Carecostsareimportantfactorsrepresentingaweightof47.43%;→ Bygender,59.38%ofmenusetraditionalmedicineand40.63%ofwomenuseit;→ Thedecisiontousemodernmedicineincreaseswiththelevelofeducation;

Conclusion: Itseemsobvious,throughthisresearch,thateffortsmustfocusbothonimprovingthedemandforcareandthesupplyinIvoryCoastforabettermatch.Strategiesmustthereforefocusonproximity,costreductionorfinancing,genderandagreaterformalizationoftraditionalmedicine,whichremainspredominant.

Keywords:determinants,choice,care,health

Factors affecting access to healthcare and efforts/challenges in securing PHC in Malawi

GeorgeJobe,ExecutiveDirector,MalawiHealthEquityNetwork(MHEN);

Background: Malawi has a three tier health system namely primary health care (e.g. healthcentres),secondary(districthospitals)andtertiary(e.g.centralhospitals).Accesstohealthcareby someMalawians is a challenge although Malawi is a signatory to the Abuja Declaration9.Malawi fails to fulfil the benchmark thereby affecting communities’ full enjoyment of primaryhealth care (PHC). Inefficiencies also negatively affect the accessibility. Some efforts areemployedtoimprovethesituationthough.

Aims:ToestablisheffectsofinadequatehealthfinancingonaccessandPHC.

Objectivesoftheresearch,

• ToestablishhowMalawiiscomplyingwithhealthfinancingbenchmarks• TocreatetherelationshipbetweenbudgetallocationsandPHC

Themethodsused,

• Deskresearch• Budgetanalysis• Structuredinterviews

9 The Abuja Declaration says 15% of national budgets should be allocated to heatlh.


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• Projects’reportsandinterventions

Thekeyfindings:Malawi’spastthreeyearshealthbudgetallocationshavebeenlowerthatthe15%Abujabenchmark.HealthhasalwaysbeenthirdinrankafterAgricultureandEducation(SeeTable). This has caused such challenges as: inadequate health workers, health facilities andequipment,andshortageofsomeessentialdrugsandambulances.Anotherchallengeisleakagescausedbytheftofdrugandmedicalsupplies,andotherformsofabuse(InterviewsandMediaReports). These challenges affect health access through both inadequate infrastructure orfacilities’ failure to provide services. Some patients walk more than 15 kilometres to reachfacilitiesdespiteGovernment’s8Kmradiuspolicy.Sometimespatientsaretoldtobuymedicinesbecauseofinavailability.TheseaffectprovisionofrequiredPCH.

Theproblemaddressedby:signingofServiceLevelAgreementsbetweenMinistryofHealthandChristianHealthAssociationofMalawionmaternalandneonatalhealthonly;assigningmultipletasks to Health Surveillance Assistants (HSAs) at community level; and Chipatala Cha Pa Foni(HealthConsultationThroughMobilePhone).MHENestablishesMotherCareGroupswho joinHSAstosensitizecommunitiesonvaccinesuptake.

Themainconclusion(s):Accesstohealthcareisaffectedbyfactorssuchaseffectsofinadequatefinancingandleakagessuchasdrugpilferage.InaccessibilitydeniescitizensPCH.

Quality improvement in community health in Kenya: estimating outcomes for investment decisions

MeghanBruceKumar,LiverpoolSchoolofTropicalMedicineJason Madan (Warwick University), Lilian Otiso (LVCT Health), Miriam Taegtmeyer (Liverpool School of Tropical Medicine)

Background: Health systems strengthening(HSS)interventionsaredifficulttolinkdirectlyto the type of clinical outcome measurestraditionally used in cost-effectivenessanalyses.Quality improvement isanexampleofanHSSinterventionthatrequireseconomicevaluation to guide investment decisions around universal health coverage (UHC) by Africangovernments and fundersworking in the region. Specifically targeted at the community level,whereproviders’workisprimarilyinpreventivecareandreferralratherthantreatment,linkstotheseoutcomemeasuresaremorelong-term,moredistalandmoredifficulttoattribute.Inthispaper,weareapplyingnovelmethodstoestimatethepotentialbenefitsof investing inqualityimprovementincommunityhealthsystemstoensurehighqualityUHC.

Aim/Objective: The objective of the paper is to evaluate the cost-effectiveness of qualityimprovementforcommunityhealthinKenya.

Dataandmethods:Weselectedantenatalcare(ANC)andtesting(foranemia,syphilis,HIVandmalaria) conducted in the first ANC visit as a tracer condition that might be identified andreferredbycommunityhealthprovidersintheselectedsettinginKenya.Wedevelopedpatientpathways for care-seeking and treatment using decision trees. At each decision node in thepatient pathway, we identified probabilities of various possible outcomes through literaturesearchandexpertopinionfromclinicalprovidersinstudysitesinKenya.

Next, we identified the probabilities most likely to vary in response to a change (qualityimprovement) in community health provider behavior based on a systemmapwe developed.

FinancialYear

Percentage ofNationalBudget

Rank ofHealth

2016/2017 10Third

2017/2018 9.9Third

2018/2019 9.9Third

Source: MHEN Budget Analysis reports


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Usingprimary costingdata from the intervention,wedetermined themagnitudeof change inintermediate,proximaloutcomesoftheinterventioninthepatientpathwaysrequiredtoyieldacost-effectivenessratiobelowtheselectedthresholds.

Keyfindings:Weshowthreekeyfindings(analysisinprogress):

1. ANCpatientpathwayincludingpre-/post-interventionprobabilities2. Systemmapidentifyingpotential impactandfeedbackloopsfromqualityimprovement

intervention3. Tableofresultsoncost-effectivenessincludingsensitivityanalysisonoutcomemeasures

Conclusions: These results should be discussed with policymakers and funders as a potentialalternativetotraditionalcost-effectivenessanalyses.Thistypeofevidence,coupledwithbudgetimpact analyses, might be more useful than incremental cost-effectiveness ratios to guidedecisionsaboutinvestmentinUHCandHSSingeneral.

The Effects of Health Care Access on Child Nutritional Status in Kenya

CorneliusKiptoo,PharmaccessFoundation,52ElMoloCourt,OffNaushadMeraliDrive,Lavington,Nairobi

Background:One third of Kenyan children suffers from stunted growth and about 2.1millionchildren under the age of five years are malnourished. Despite interventions put in place toaddress poor child health indicators, nearly 45%of the under-five’s deaths occur due to poornutrition.Childhealthdependsonaccesstohealthcareservicessuchas immunization,propernutrition and quality management of childhood illnesses. However, little is known on thesignificanceofthesevariationsontheutilizationandimpactsontheultimatehealthstatusofthechildrenandhencethebasisforthisstudy.

Aim:ToexploretheeffectofhealthcareaccessonchildnutritionalstatusinKenya.

Method: This study utilizes a cross sectional Kenya Demographic Health Survey of 2014.Weemployedbinaryprobitmodeltoestimatetheprobabilityofachildbeingstunted.Accesstocarewas the outcome variable andwasmeasured using distance as being near or far from healthfacility.Nutritionalstatuswasthedependentvariableandwasmeasuredusingheightforagezscores. Confounding variables were maternal factors such as age of the mother, education,breastfeeding, place of residence, and regions. We controlled for sample design, andheterogeneityfromunobservedcharacteristicscorrelatedwithstunting.

Results:AccesstochildhealthsignificantlyinfluencestheprobabilityofachildbeingstuntedinKenya. Older women and secondary education were found to reduce stunting. On the otherhand, being married, breastfeeding, and living in urban area were associated with increasedstunting. In terms of regions, the coast, north eastern, eastern, and Nyanza lowered theprobabilityofachildbeingstunted.

Conclusion:Moreeffortsarerequiredtoenhanceprioritizationofpolicyformulationforbetterchild nutritional outcomes. This includes the need for government intervention to addressdistance barriers of access to essential health care hence achievement of Sustainabledevelopment goal number 2.2 and enhance primary healthcare. Both regional and specificcountyhealthpoliciesshouldbedesignedintherespectiveandsignificantregionsthatisgearedtowards integrated people-centered care systems. Overall, the government needs to addressbarriers in healthcare access for its citizens either financial or distance in order to achieveuniversalhealthcoverage.

Keywords:stunting,childhealth,access


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Pathways to care for patients with Type 2 Diabetes, HIV/AIDS and other chronic comorbidities in Soweto: A Health System’s Perspective

EdnaBosire1,2,ShaneNNorris1,JaneGoudge2,EmilyMendenhall1,31MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), School of Clinical Medicine,FacultyofHealthSciences,UniversityoftheWitwatersrand,Johannesburg,SouthAfrica2Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of theWitwatersrand,Johannesburg,SouthAfrica3Science, Technology, and International Affairs Program, Walsh School of Foreign Service, GeorgetownUniversity,Washington,DC,USA Background:SouthAfricahasahighburdenofcollidingepidemicsofHIV,tuberculosis(TB),Type2diabetes(T2DM),and/orhypertension(HT),andinmanycasespatientshavemorethanoneofthese conditions. The National Department of Health (NDoH) in South Africa initiated theIntegratedChronicDiseaseManagement(ICDM)modeltorespondtothishighdiseaseburden,which integrates theHIVplatformwithother chronic conditions.However, themodel hasnotbeenimplementedinmostclinics.Instead,amultiplelevelsystemrequirespatientstoseekcarefrom primary health center in their community and specialty medical care at hospitals uponreferral.

Objective: This researchproject investigates the trajectory andpathways topatient care fromprimaryhealth care (PHC) to a tertiaryhospital in a low-incomeneighborhood inurban SouthAfrica through ethnographic researchmethods. The project focuses on patient and providerexperiencesandperspectivesofhowthehealthcaresystemfunctionstocare forpatientswithcomorbidT2DMandHIV.

Methods: We employed ethnographic and survey methods. The first author observed theworking of primary health care clinics and specialty clinics in the tertiary hospital. This alsoinvolvedlengthyinterviewswithactorswithinthehealthsystem-administratorsandhealthcareproviders (from different disciplines, N=30) and patients (N=50). Field notes from clinicalobservationsandqualitativeinterviewsweretranscribedandanalyzedverbatimwiththeaidofQSRNVivo12software.

Results:WefoundthatpatientswithcomorbidT2DMandHIVattendmultiple,differentclinicsfor care,which isdiseasespecific.Despite legislation thatpromotes integratedcare,we foundlimitedcollaborationacrossdifferentlevelsofcare.Gapsidentifiedwereatthereferralsystem,non-unified/centralized records, poor communication between providers, non-involvement ofpatientsandtheirfamilies indecisionmaking,andoverburdeningworkloadinpartduetostaffshortage.

Conclusion:PHC facilities inurban SouthAfricahavenotbenefited from the ICDMmodel andthis has produced an overburdening of public hospitals. Limited collaboration betweenhealthcare providers across different levels of care as well as lack of coordination betweenproviders, patients and their families necessitate the need to strengthen the health system inorder to address the existing gaps. Without putting people first, integrated and collaboratedhealthcare would still face challenges because no established direct relationship betweenindividuals,familiesandhealthcareprovidersexists.

Factors Inhibiting Effective Utilisation of Primary Health Care Services in Eredo Local Council Development Area of Lagos, Nigeria OlusogaShittu,WestAfrica:PoliceAcademy,Wudil,Kano–Nigeria


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The objective of primary health care (PHC) services is provision of accessible and affordablehealth forall by theyear2000andbeyond. InNigeria, thereare some factors that inhibit theoptimal utilisation of PHC services vis-à-vis educational, religious, socio-cultural and financial.This paper examines factors inhibiting the effective utilization, under-utilisation and non-utilisation of primary health care (PHC) services usage among the residents of Eredo LocalCouncil Development Area of Lagos, Nigeria. Being an exploratory study, a qualitativemethodologywasadoptedwhereindatawerecollectedprimarilyfromtherespondentswiththeaid of In-depth Interview (IDI). Multi-stage sampling techniques were used to select therespondents for the study. 20 respondents from each of the 6 PHC centers comprising ofOdomola, Eredo, Ilara, Ibonwon, Igbonla and Mojoda were systematically selected using theclinic registerwhile thehealthpersonnels ranging fromMedicalofficerofhealth (MOH),ChiefApexNurse andOfficer in charge (OIH)were purposively selected and interviewed. The studyfindsoutthatinadequatePHCcenters,lackofproperreferralsystem,corruptionamonghealthcare personnel, inadequate Doctors Patients Ratio (DPR), inadequate funding among othershavebeenidentifiedassomeofthefactorsinhibitingtheproperutilisationofthesePHCcenters.The study concluded that for PHC services to be effective and imbibed there should be aparticipatory approach between the government and the community stakeholders as healthproblemsshouldbeproperlydefined,planned,implementedandproperlyevaluatedinordertoachieveitsstatedobjectives.

Keywords:Community,healthcare,utilisation,primaryhealthcare,strategies.

Determinants of access to Ivorian public hospitals: An analysis by the counting model.

AmamyElyséeETIEN,FélixHouphouët-BoignyUniversity

Context: Access to care is critical in assessing the quality of health care systems. Among thefactors of poor quality of care related to access, we can count the death, disability orrenunciationoflong-termcareofpatients.InCôted'Ivoire,accessibilitytocareismadedifficultbecauseofmanybarriers. The2015Household LivingStandardsSurvey (ENV-2015)notes that52%ofhouseholdshavetotravelatleast5kilometerstoreceivemodernhealthcare.Thelengthof the journey, the state of the road and the monetary costs of transportation and medicaldiagnosis discourage patients. The situation becomes more critical when one looks at theconditionsofaccessofgeneralhospitalsandregionalhospitals.However,reportsonthehealthsituationof theMinistryofHealthshowthat theiractivity ismainly focusedonprimaryhealthcare (40% in general medical consultations and 28% in pediatric and gynecological obstetricconsultations).

Goalsandobjectives:Thisstudyaimsto identifythedeterminantsoftheuseofhealthcare inIvorianpublichospitals.Morespecifically,itisaquestionofdeterminingthesocio-economicandhealthfactorslikelytoincreasethenumberofconsultationsinthesehospitals.

Methodsused:Usingasampleof4,308individualswhoreportedhavingusedcareinamodernhealth center in the 4 weeks prior to 2015, we established the frequency of use of publichospitals. Therefore, we used the negative zero-inflation binomial model to estimate thecoefficientsofthefactorsthatcouldincreasethenumberofpatientconsultationsinhospitals.

KeyFindings:Theconsultationfee,prescriptionandtransportationfeespositivelyinfluencethenumberof consultations inpublic hospitals. Compared tomen,womenaremore likely tousecareinthehospitalsystem.


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Keyfindings:Theresultsshowthateconomicfactorsarenotareasonforgivingupcareinpublichospitals in Côte d'Ivoire. We recommend that Ivorian decision-makers in the health sectorintegrate hospitals into the primary health care extension strategy as part of universal healthcoverage.

Keywords:Accessibility,IvoryCoast,Hospital,Countingmodel.

Obstacles and factors facilitating access to sexual and reproductive health (SRH) services for young people living with disabilities (YLD) in Senegal

FatouKebe,EvaBurke,AlexLeMay_DakarGRESAFRIC

Background: Recent initiatives have sought after prioritising young people in sexual andreproductivehealth(SRH)policiesandconventionsinSenegal.Commitmentshavebeenmadetodefend the health rights of people living with disabilities (Article 17 of the Constitution).However, research on the use of SRH services among young people with disabilities (YLD) isnegligible.OurstudyexploredSRG'sprioritiesforYLD,keyvulnerabilitiesandaccesstoservicesincludingpreferencesandbarrierstoaccessingtheseservices.

Methods: 17 focus groups and 50 individual interviews were conducted with YLDs havingreducedmobilityorwithvisualorhearingdisabilitiesaged18to24 inDakar,andKaolack,andThiés.Apeerapproachwasusedfordatacollectionandanalysis.

Results:TherewasalowawarenessanduseofSRHservicesamongYLDs.TheyweredependentonSRHservicesforaccess,whichhindersconfidentiality.Theuseofcontraceptivemethodswasrelativelylimitedtocondoms.Multiplecasesofrapehavebeenreportedamongwomenhavinghearing disabilities. The main barriers to SRH services for YLD were financial barriers, healthagent/parentattitudesandaccessibility(relatedtotheirdisability).ThestudyfoundlittleornouseofexistingandspecificSRHstrategiesforyoungpeopleinSenegal.Inaddition,nomentionwas made of access to the new initiative on free health services for people with disabilities(equalopportunitycard).

Conclusions:Ageanddisabilityareconstraints forYLD toaccessSRHservices.YLDwomenaremoreconfrontedwithconstraints,inconnectionwithsocialnorms(preservationofvirginityuntilmarriage). Interventions to increaseaccess to servicesmustconsiderdisability-specificbarriersand gender norms. The recent national initiative to introduce free care for people withdisabilitiesmustbeaccessible/appropriateforYLDbutshouldalsobesubsidizedattheprivatelevel.Furtherresearchonpeople livingwithdisabilities isneededtoexplorethe loadofsexualviolence,theroleofhealthagentsinsupportingrapecases,thedeterminantswhetherYLDusescontraceptivemethods.

Towards Effective Implementation of Maternal and Child Health Programmes in Nigeria: Lessons for Policy Makers

Chinyere.C.Okeke1,BSCUzochukwu1,2,IfeyinwaArize1,ObinnaOnwujekwe11Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine,UniversityofNigeriaEnugu-Campus,Enugu,Nigeria.2Department of CommunityMedicine, College ofMedicine, University of Nigeria Enugu-Campus, Enugu,Nigeria.

Background: The distressing maternal and neonatal health indicators in Nigeria are notimproving despite various interventions. Though progress was initially recorded in reducing


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maternaldeaths,thenumberofwomenwhodieinpregnancyorfromcomplicationsassociatedwith childbirth remains significantly high in Nigeria. It has increased from 576 per 100,000 in2013to814per100,000in2018.

Development partners have in many cases shut down or scaled back operations and publichealth experts fear that this will attenuate the health gains of the last decade as alreadypresenting. Limited improvement inhealthmayalsobepartly explainedby lateoffset, lackofsustenance, disjointeddesign andnon-scaling upof implementationof interventions targetingmaternalandchildhealth(MNCH).

Currently, policy recommendationswhich favourMNCH interventions should be designed andimplemented to address fundamental etiological factors of the mother and child through acomprehensiveandcontinuumofcareapproach.Inaresourceconstrainedsetting,interventionsshouldbedesignedtoensureefficiencyandcost-effectiveness.

AimsandObjectives:ThisstudyaimedtoexaminethepastexperiencesofMNCHprogrammes,with a view to identifying the enabling and constraining factors for implementation andeffectiveness,andtheopportunitiesforadaptationandprogrammescale-upinNigeria.

Methods:Anexploratory,descriptivequalitativestudyusingmultiplecasestudydesignwasusedfor thestudyat thenationalandstate levels inNigeria.Datawascollected throughdocumentreview, in-depth interviewsand focusedgroupdiscussionsandanalysedusingmanual contentanalysis.

Key Findings:The study revealeda lackof coordinationofpoliciesand interventionseitherassource of evidence for initiating intervention or its evaluation. Furthermore, the scale anddurationofmanyof the interventionswas insufficient tohavedemonstrable impactonMNCHoutcomes.Anumberof interventionswere implementedaspilotsorwithin the frameworkofverticalprogrammestherebyraisingconcernsforscaling-upforwidercoverage,integrationintothehealthsystemandsustainability.Hesitationanddelaysbythesub-nationallevelstopaytheircounterpart funds in carrying out national programmes and much dependence on externaldonors affects the ownership, implementation and sustainability of such programmes, whichusuallyhasabearinginthePHCfunctionalityinNigeria.

Conclusion: This study provides important lessons for policy makers to set evidence basedagendas for understanding MNCH problems and institution of relevant interventions. Earlyengagementofall tiersofgovernment innationalactivities iskeytoproper implementationofprogrammes.

Parallel Session 8-6 Hospital management and financing

Hospital efficiency in healthcare use: A case study of Rwanda

BIRINDABAGABOPascal,MinistryofHealthATAGUBAJohn,UniversityofCapeTown Background: Efficiency and Equity are the key objectives of health system that deemed to beresilient to ensure themove toward universal health coverage, importantly in the SDG’s era.However, evidence show that hospitals in developing countries remain inefficient in term of


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using the scarce resources and yet, they consume the greatest shareof fundsdevoted to anyhealth care system globally, hence the failure of providing healthcare services needed toeveryone mostly the poorest one. This study aims to assess the relative efficiency of districthospitalandequityinhealthcareuseinRwanda.

Methods: Data Envelopment Analysis and concentration curves were used in this study tomeasurehospitalefficiencyandequityintheuseofhealthcareinRwanda.

Results: The results from this study revealed that the mean technical efficiency of Rwandandistricthospitalwas94.5%.Andonly60%ofdistricthospitals are relatively technical efficient.Therefore, almost 40% of district hospitals are wasting their inputs compared to the bestperformerdistricthospitalsofallinputsusedatdistricthospitallevelsasconsideredinthisstudyarebeingwasted.

Intermofequityinuse,theconcentrationcurvesrevealedthattheuseofmostmalariaserviceswere pro rich unless the inpatient serviceswhichwasmore concentrated in the poor districtwhilethemostoftheservicesrelatedtoallthediseasesareconcentratedinthewell-offandallthe use of related services were pro rich only inpatient related tomalaria was pro poor andassisteddeliverywhichwassomewhatequitableinalldistricts.

Conclusion: This study has demonstrated that there are inefficiencies in the use of inputs indistricthospitalswhileacertainlevelofequityinusinghealthcareservicesinRwandaHealthcaredeliverysystem.Italsofindssomepatternbetweendistricthospitalefficiencyperformanceandtheuseofsomeservices.Itisthenarguedthatmoreeffortintermofmentorshipshouldputinthedistrictwithinefficienthospitalswhileforimprovingtheequityinuseofhealthcare,servicesshouldbedecentralizedtoallowaccessbutalsohealthcareresourceallocationshouldbebasedavailable data inHealth InformationManagement System. Thiswill enable to allocate existingresourceinhealthsectoraccordingtoexistingneed.Futurestudiesshouldlookatthecausesofdistrict hospital inefficiency or investigate inequality in use ofmalaria andmaternal health aswellastheirdeterminantfactors.

Relationship between organisational justice and work-related behaviour of health professionals: evidence from public hospitals in South-east Nigeria.

GhasiNwanneka1,OnodugoVincent1andOgbuaborDaniel21Department of Management, Faculty of Business Administration, University of Nigeria Enugu Camus,Enugu,Nigeria.2InstituteofPublicHealth,CollegeofMedicine,UniversityofNigeriaEnuguCampus,Enugu,Nigeria.

Background:Thereisgapinknowledgeabouthowemployee-centredhumanresourcespracticesinfluencethework-relatedattitudesandbehavioursofhealthprofessionals in lowandmiddle-incomecountries.

Aims and objectives: The aim of this study was therefore to investigate the effect oforganisational justice on task performance (TP) and counterproductivework behaviour (CWB)amonghealthworkersinpublichospitalsinSouth-eastNigeria.

Methods: A cross-sectional questionnaire survey which involved 370 health professionalscomprising 84 doctors, 186 nurses and 100 allied health professionals (AHPs) selected from 5public tertiary hospitals in South-east Nigeria using multi-stage sampling technique wasconductedbetweenJanuaryandApril2018.Meanscoredifferencesweretestedusingstudentt-testandanalysisofvariance(ANOVA).Multivariateanalysiswasusedtotestpredictionmodelsforwork-relatedbehaviours.Statisticalsignificancewassetρ<0.05.


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Results: The results showed that, overall, the mean score of organisational justice was 3.05(0.96).Mean(SD)scoresfordistributivejustice,proceduraljusticeandinteractionaljusticewere2.70(0.94), 3.17(0.91) and 3.09(1.03) respectively. There were significant mean scoresdifferences in perception of organisational justice, TP and CWB among different categories ofhealthprofessionals.Overall,TPwaspredictedbyeducation(β=0.216,ρ<0.05), tenure(β= -0.103, ρ<0.05) and CWB (β =-0.141, ρ<0.05).Marital status (β = -0.311, ρ <0.05), distributivejustice(β=-0.166,ρ<0.05)andtaskperformance(β=-0.185,ρ<0.05)predictedCWB.Withinthesub-groups,TPamongdoctorswaspredictedbygender,maritalstatus,andprocedural justice.TenurepredictedTPfornursesonly.AmongAHPs,onlyhospitalpredictedtaskperformance.Agesingularly predicted counterproductive work behaviour among doctors (β = -0.216, ρ <0.05).Amongnurses,marital status (β= -0.400,ρ<0.05),distributional justice (β= -0.624,ρ<0.05),interactional justice (β= -0.496,ρ<0.05)andoverallorganisational justice (β=0.763,ρ<0.05)predicted counterproductive work behaviour. Hospital location singularly predictedcounterproductiveworkbehaviouramongAHPs(β=0.180,ρ<0.05).

Conclusions: We conclude that CWB mediated the effect of organisational justice on taskperformanceofhealthprofessionalsinNigerianpublichospitals.Whereasproceduraljusticewasimportant among doctors, distributional and interactive justice was significant to nurses.Optimizingperformanceofhealthprofessionalwouldrequireattentiontothesepeculiaritiesandcontext-specificdifferencesindemographicandworkplacecharacteristics.

Secondary hospital efficiency analysis in Ethiopia: Technical and scale efficiency applying data envelopment analysis method

EliasAsfawZegeye1andErmiasDessie21 University of California Davis (MINIMOD Project) & The Children Investment Fund Foundation (SURE Program), Addis Ababa,Ethiopia,2FederalMinistryofHealth,HealthEconomicsandFinancingAnalysisTeam,AddisAbaba,Ethiopia

Background:Ethiopiahasabletoeffectivelyachievebetterhealthgainsforthepopulationwithabroadervisionofseeinghealth,productiveandprosperouscitizens.Understandingitsrelevanceefficiency,effectivenessandevidencebaseddecisionmakingaretakingthepriorityobjectiveinthe five year strategic objectives of the health sector (FMOH, 2015). The efficiency analysiswouldbeexpectedtobeenhancedacrossdifferenthealthtiers:primary,secondaryandtertiarylevel.

Objective: This efficiencyanalysis aims togenerate technical and scaleefficiencyof secondarylevelhospitalsinEthiopiaandassessthepossibleinputssavingfortheseinefficiencies.

Methods: The costing study was retrospective, facility-based and employed cost accountingtechniquestoidentifyandmeasurethecostsincurredindeliveryhealthservicesatthefacility-level.Anationallyrepresentativesampleof12hospitalsatthesecondarycarelevelwasincludedfor thecostinganalysis.Theefficiencyanalysiscomputed to the relationshipofhospital inputs(humanresources,drugsandmedicalsupplies,depreciatedequipmentand indirectcostat the2017 costing base year) and outputs measured in the outpatient equivalent visits. Dataenvelopment analysis (DEA) non-parameter technique was applied to analysis total hospitalefficiencyanddepartment-levelefficiency.

Findings:Humanresourcesandmedicalsuppliesaccountsformorethan50%ofthecostacrossthe surveyed secondary hospitals. Of the twelve surveyed secondary hospitals, two hospitals(Bishoftu and Kemise) were technically efficient while the remaining ten hospitals weretechnically inefficient in 2016/17. The overall average technical efficiency score among theinefficienthospitalsis66%.Onaveragethesecondaryhospitalscouldreducetheirinputsby34%without reducing thecurrentoutput level.Throughreducing the inputs, there isapotential to


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saveatotalof192.5millionbirr(withoutanyreductioninoutputs).Theaveragescaleefficiencyscoreamong inefficienthospitals is15%, inferringapotential to increase totaloutputsby85%withintheexistingcapacityandsize.

Conclusions: Themajority of secondary hospitalswere inefficient and a significant amount ofinputsresourcescouldbepotentiallyreduced.Thereexistahugepotentialto increaseoutputs(almostby85%)withthecurrentexistingcapacityandsize.Butthisprobablydependsonotherfactorssuchas:increasingserviceacceptability,qualityandawarenesscreation.

The determinants of healthcare quality among the private and public hospitals in Ibadan Metropolis, Nigeria.

BosedeOlanikeAWOYEMI(PhD)1,ProfessorOlanrewajuOLANIYAN21DepartmentofEconomics,AfeBabalolaUniversityAdo-Ekiti,EkitiState,Nigeria.2DepartmentofEconomics,UniversityofIbadan,Ibadan,Nigeria.

Healthcare quality assessment among hospitals incentivize the performance of the healthcaresystem and gives room for improvement. Quality of healthcare differs across hospitals, somehospitalsinordertoincreasetheirmarketshareofpatients,providehigherqualityofhealthcare.InNigeriatherearefewnumbersofpublichospitalscomparetoprivateandthepresumablyfewexistingpublichospitalsareconfrontedwithuniquechallengesofinadequatefundingandlackofproper supervision, which threaten their existence. These situations have made the privatehospitalsunavoidablechoiceofmanypatients.However, it isnotedthattoo littleregulation isbeingenforcedtoensurethatminimumqualitystandardsaremetamongtheprivatehospitals.Therefore, this studyexamined the factors that influence thequalityof healthcare among theprivateandpublichospitalsinIbadanmetropolis.

Tomeasurethequalityofhealthcare,inputandpatientqualityexperienceindicatorswereused.Six(6)differenthospitalinputswereemployedandthepatientqualityexperienceindicatorwaspresentedasan indexof thepatient’s levelofsatisfactionwithhospitalqualitydelivery.Giventhe continuous nature of the dependent variables, Ordinary Least Square (OLS) was used toidentifyfactorsthatinfluencehealthcarequalityamonghospitals,whiledescriptivestatisticswasusedtodescribedifferentattributesofprivateandpublichospitals.Dataweredrawnfrom127hospitalsand761patientsthatattendedthesehospitalsInIbadan.

Theresultsofthestudyshowthatontheaverage,patientqualityindicatorforprivatehospitalsis 0.81which indicates a higher level of satisfaction than in the public hospitals. The averagehealthcare price paid by patients and quarterly visit by regulatory agencies, motivate privatehospitals to increase quality of healthcare, while regulation on human resources and patientvolume motivate public hospitals to produce higher quality of healthcare. Thus, healthcarereforms that will ensure strict compliance with the hospital establishment procedures andminimizenegligenceamonghospitalsisrecommended.

Keywords:Hospital,Healthcarequality,Patients,Ibadan

Productive efficiency of the Ivorian hospital system: an analysis by the DEA-Malmquist

AmanyElyséeETIEN,Abidjan,universitéFélixHouphouet-Boigny

Context: Since the Harare conference, health care delivery systems in African countries havebeen pyramid-shaped at three levels. The Ivorian hospital system is characterized by anincreasing evolution over the years of the number of level 2 health centres in the health


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pyramid.However,hospitalactivity isdeclining in favourof first contacthealthestablishments(level1).

Aimsandobjectives:Inresponsetothisalarmingsituation,thisstudyaimstoexplainthelossofattractivenessofgeneralhospitalsandregionalhospitals.Inotherwords,theaimistoassesstheproductiveefficiencyofthesehospitalsandtodeterminethesourcesoffactorproductivity.

Methodologies: Using data from theMinistry of Health and Public Hygiene's health statisticsyearbooks (2012; 2013 and 2015), the Data Wrapping Method (DEA) is used to calculatetechnicalefficiencyscoresandtheMalmquistIndexforfactorproductivityanalysis.

Keyfindings:Undertheassumptionsofvariablescalereturnsandoutputorientation,theresultsshowthattheaveragetechnicalefficiencyscoreis0.798overthethreeyearsofstudy.Hospitalsare therefore technically inefficient.Theaverage scoreof the regionalhospitals is thehighest.Andon theotherhand,Malmquist's productivity index averaged1,053over the studyperiod.Thus,thereferencehospitalshavegenerallyimprovedthetotalproductivityoftheirproductionfactors by 5.3%. This improvement is explained more by the change in efficiency than bytechnologicalchange.

Main conclusions: Based on the above results, actions such as training hospital managers inmanagerial techniques, motivating health human resources and strengthening the technicalplatformwillcontributetoimprovingthequalityoftheIvorianhospitalsystem.

Keywords:IvoryCoast,Technicalefficiency,Hospital,Productivity.

Attributable Cost and Extra Length of Stay of Surgical Site Infection at a Ghanaian Teaching Hospital

AmaFenny,LegonUniversityofGhana

Background: Limited information is available on the financial impact of surgical site infections(SSI)inGhana.TocalculatethecostofSSIsinasurgicaldepartment,aprospectivecase-controlstudywasundertakenattheKorleBuTeachingHospital(KBTH)inGhana.

Methods:We studied 446 adults undergoing surgery from the surgical department. In all, 41patientswithSSIand41controlpatientswithoutSSIwerematchedbytypeofsurgery,woundclass,ASA,sexandage.Thedirectandindirectcoststopatientswasobtainedfrompatientsandtheir carers on daily basis. The cost of drugs was confirmed with the pharmacy at thedepartment.

Results:PrevalencerateforSSIwasfoundtobe10.2%ofthetotal446casessampledbetweenJune and August 2017. On average patients with SSI who undertook appendix surgery paidapproximately GHC1,210 ($256)more than thosewithout SSI in the same category. The leastdifferencewasrecordedamongstpatientswhohadthyroidsurgery,adifferenceofGHC62($13).Theresultsshowthat forall surgicalprocedures,SSIpatients reportexcess lengthofstay.Theextradaysrangefrom1dayfor limbamputationto16extradays forrectalsurgery.However,theregressionestimationshowedthatALOSisnotsignificantlyinfluencedbySSIstatusalthoughALOSpartlyaccountforvariationsintotalcostbornebySSIandnon-SSIpatients.

Conclusions: In this study, patients with SSI experienced significant prolongation ofhospitalisationand increaseduseofhealth care costs. Inmany cases, the indirect costsweremuch higher than direct costs. These findings support the need to implement preventativeinterventions forpatientshospitalised forvarioussurgicalproceduresat theKorleBuTeachingHospital.


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Definition of Universal Health Coverage and Primary Health Care Practice at Kayes Hospital

DrMakanSOUMARE,KayesHospitalPharmacistDr.JonasKAMATE,hospitalpharmacistofKayes The research is done to check the state of the services of thehospital of Kayes and it is half-yearlyand it isamethodof investigationof theheadsof servicesof thehospitalmadeby themedicalcommissionofestablishment.

ThegoalofUniversalHealthCoverageistoensurethatallindividualshaveaccesstothehealthservicestheyneedwithoutincurringfinancialhardship.

Primaryhealth care (PHC) is a health strategy strongly basedonprevention and implementedthroughthecommunityparticipation1of thepopulations, to improveandmobilizeatbest theavailablelocalpeopleandmeans,butalsotopromotethediffusionofknowledgeandbehaviorsandattitudesof"prevention"withinthecommunity,orevenneighboringcommunities,byspin-offs.

IntheservicesthatmakeupKayesHospital,thereisashortageofhealthstafforaninsufficientcareofpatients,lackofaccesstocareforthesick

Ontheotherhand,alackofnecessaryequipmentandtheunavailabilityoffundsnecessaryforthefinancingofactivitieswithinthehospital,financialdifficultiesforhealthstaffandpatients

Overall, the failure to respect themeans of financing and support by the government of ourcountry.

Hence theneed todrawtheconclusion thatuniversalhealthcoverage isnotapplicablewithintheKayeshospital,andat thesametimeprimaryhealthcare isnotessential inourcountry inMali.

Keywords:Healthworkers-care-sick

Parallel Session 8-7 National health Insurance

Examining the Extent of Balance billing in the Ghanaian National Health Insurance.

EugeniaAmporfu,KwameNkrumahUniversityofScienceandTechnology

Background:TheGhanaianNationalHealthInsuranceScheme(NHIS)wasestablishedin2003torelieveresidentsoftheoverburdenedhealthcareuserfee, locallyknownasCashandCarry,byofferingsocialhealthinsuranceservice.Sinceitsestablishment,theNHIShasprovidedfinancialprotectiontoitsmembersbyofferinghealthcareinmorethanthreethousandaccreditedhealthfacilities. Under the NHIS, members make no co-payment for services covered implying thatproviderscannotchargebeyondthefeepaidbytheNationalHealthInsuranceAuthority(NHIA)forcoveredservices,hencebalancebillingisillegal.Balancebillingreferstoaprovidercharginganinsuredpatientabovewhatheorsheisobligedtopayandwhattheinsuranceisalsoobligedtopay.SinceNHISmembersarenotsupposedtomakeco-paymentatthepointofservice,andtheNHIS is supposed to pay the provider directly, any paymentmade by insured patients for


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covered services is a form of balance billing. Even if consumers are balance billed, by a smallpercentage of the fee it could constitute catastrophic healthcare expenditure depending toconsumers’ ability to pay. There have been anecdotes of NHIS providers engaging in balancebillingbutnoformalresearchhasbeendonetoexamineit.

Objective:Thepurposeof this study is to verify theexistenceofbalancebilling, theextent towhich it imposescatastrophichealthcareexpenditureonmembers,andmembers’ responsetobeingbalancebilled.

Methods: thestudyuseddatawerecollected fromKumasiandAccra, the two largestcities inthe country, with a sample size of 500 per city, 300 insured and 200 uninsured, usingconvenience sampling. Catastrophic expenditurewas computed. In addition, regressionswererun toexamine theextentofbalancebillingand the responseof the insured tobeingbalancebilled.

Results: The results showed that balance billing is practised extensively,more in Kumasi thanAccra, causing catastrophic expenditure to the insured. Providers were not likely to admit toengaging in balance billing. The insured were mostly unaware that they were being balancebilled.ThosewhoknewwerenotlikelytoreporttotheNHIS.

Conclusion: Balance billing needs to be addressed if the NHIS is to be the channel to theachievementofuniversalhealthcoverage.

An economic evaluation regarding the benefits package of Ghana’s National Health Insurance Scheme

HeleenVellekoop,MinistryofHealthGhana Background:Ghana’sNationalHealth InsuranceScheme (NHIS)was initiated in2003,with theaimofachievingUniversalHealthCoverage.However,NHISperformancehasbeenchallengedbyfinancial sustainability issues. The NHIS has faced deficits since 2009. Healthcare providersreceive reimbursements ninemonths late on average. A revision of the benefits package hasbeen suggested as a mitigating measure and policy-makers are investigating the option ofincludingonlyprimaryhealthcare(PHC)interventions.

Objectives:Weconductedaneconomicevaluationwiththeobjectivetogiverecommendationsregardingtheinterventionstobeincludedinarevisedbenefitspackage.Ascenarioanalysiswasperformed to provide insights into the outcomes of various options for the benefits package,includingtheoptionoffocusingonPHC.

Methods:70 interventionswerecostedusing localdatasources.Dataonthehealthbenefitofeach intervention (measured in Disability-Adjusted Life Years (DALYs) averted) was collectedthrough a literature search. Subsequently, thenet health benefit of each intervention (DALYsaverted)wascalculatedandusedtoranktheinterventions.

Sixdifferentbenefitspackagesweredesigned,basedondifferentpolicyaims.Theexpectedtotalcostsofthepackageswerekeptwithinabudgetdrawnfrom2017expenditureonNHISclaims.Foreachpackagewereported:totalcost;budgetimpactperdiseasearea;totalDALYsaverted;totalcasestreated;andnumberofinterventionsincluded.

Findings:Themostbeneficial interventionswerefoundtobe intheareasofmalaria,maternaland neonatal care and reproductive health, while interventions in the areas of NCDs andneurologicalandpsychologicaldisorderstendtobelessbeneficial.

We found that aiming to maximise DALYs averted in designing the benefits packages alsoachieves good results in other areas of interest. Focusing on including a high number of


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interventions,asopposed tocoveringa largerproportionof thepopulation, leads to low totalhealth benefit and number of cases treated. Including all available PHC interventions in thebenefits package is unlikely to be possible with the current NHIS budget. Introducing co-insuranceappearsapromisingavenuetoachievegoodoutcomes.However,furtherresearchisneeded.

Key recommendations: We recommend for population coverage to be prioritised overintervention coverage. Emergency obstetric and neonatal care should be included in any PHCpackage, despite being higher-level care, as these interventions are highly beneficial.We alsorecommend increased efforts to build technical capacity in the field of health technologyassessmenttoenablefurtherresearch.

JIS0GH A checklist for designing and developing contributory health insurance programs in Nigeria

YewandeOgundeji,KelechiOhiri,AzaraAgidaniAbujaHealthStrategyandDeliveryFoundation

Thereiswidespreadandgrowinginterestinachievinguniversalhealthcoverageacrossmanylowand middle-income countries by way of designing and implementing social health insurance(SHIS).SHISrecentlygainedtractioninNigeriathroughtheNationalHealthActandmanystatesare planning to design and implement SHIS. However, some states strugglewith designing anoptimalSHISscheme,which is importantbecause literaturesuggeststhatfailuresorsuccessofSHISaretoacertainextentdependentonthedesignfeatures.Therefore,itiscrucialtoexaminethesuitabilityandreadinessbeforeimplementationofSHIinanygivencontext.

InNigeria, evidence regarding optimal design features of SHIS is sparse and there is lack of asimple and standardized checklist, which scheme designers, implementers, and researcherscouldusetoassessreadinesstoimplementSHISortoguideandinformthedesignofSHIS.

This paper describes the development of a SHIS checklist and demonstrate that the newlydevelopedchecklistconsistingofsixdesigndomainswhichcanbeusedbyschemedesignersandpolicymakers, as a simple andeffective tool to assess and informSHISdesign features acrossNigeriatomaximizethechancesoftheeffectivenessoftheschemes.

Delayed provider claims reimbursement challenges: a decade after the implementation of the National Health Insurance Scheme Policy in Ghana. Time to rethink.

AlexanderSuukLaar1MichaelAsare2,PhilipAyizemDalinjong31UniversityofNewcastle,SchoolofPublicandMedicine,FacultyofHealthandMedicine,Australia.2HolyFamilyHospital,Nkawkaw,EasternRegion,Ghana3NavrongoHealthResearchCentre,PostOfficeBox114,Navrongo,UpperEastRegion,Ghana.

Background:Toensurethatallpeoplecanaccessqualityhealthservicestoprotect themfrompublichealth risksand impoverishmentdue to illness, fromout-of-pocketpayments forhealthcare, the government of Ghana implemented theUniversal Health Coverage (UHC) under theNational Health Insurance Scheme (NHIS) in 2005. However, over a decade of itsimplementation,reimbursementofclaimstoprovidersisthreateningthetrustandsustainabilityofthescheme.

Aim: To find innovativeways of addressing the current challenges, this study explored healthprofessionals’viewsonkeypolicyinterventions.


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Methods:Aqualitative studycomprisingof16key informant interviews (KIIs)wereconductedwith

health professionals comprising of 4 hospital directors, 4 claims managers, 4 hospitaladministrators and 4 accountants in four districts in the Eastern region of Ghana. Theparticipantswerepurposivelyselectedfromthreepublichospitalsandonemissionhospital.Thedata collection tool was in-depth interviews using open-ended interview guide. Thematicframeworkwasutilizedfortheanalysis.

Results: Themain findings of this studywere: long delays of claims reimbursement to healthfacilities ranging fromseven(7) toten (10)monthsontheaverage. Theyalsomentionedthatthe current phenomenon affects the quality of healthcare provided to clients since in someinstances, clients are compelled to make co-payments or out-of-packet payments for healthcare. The participants attributed the current challenges of the scheme to inadequate funds,manualprocessingofclaimsandpoliticalinterferenceintheactivitiesofthescheme.Togetridof the current challenges bedevilling the scheme, participants suggested the need for thegovernmenttoexplorealternativeandsustainablesourcesoffundingbylevyingspecialtaxesonmobileandmoneytransferandotherprofitablecompanies,allocationofacertainpercentageoftheoilrevenueandraisingoftheValueAddedTaxonhealthcaretosupportthehealthbudget.Computerization of the claims system and decoupling of politics from the schemes activitieswerealsosuggested.

Conclusion: The implicationof delayed claims reimbursement andprovision of health servicesdrawscriticalissuesonqualityandequityofcare.Toaddresssomeoftheissuesidentifiedinthisstudy,thegovernment,policymakersandimplementersneedtoconsiderourrecommendationstoensurethesustainabilityofthescheme.

Keywords: Universal Health Coverage, claims delays, claims reimbursement, Health facilities,Ghana.


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Posterpresentations


PosterPresentation1 Analysis of factors associated with using health facility-based care for fever in children aged 0-5 years in Ivory Coast

YAPIApollinaire1;ORSOTTétchi1,2;AmedCOULIBALY1,2;SABLEParfaitStéphane1,21NationalInstituteofPublicHealth-ABIDJAN2UniversityofFélixHOUPHOUET-BOIGNY

Introduction:Thepresenceoffeverinchildrenisoneofthemainreasonsforparents'consultations.The time between the onset of fever and the health consultation is sometimes long and exposeschildrentoemergencies.Mostoften,parentsuseseveraltypesofconsultationsdependingontheirmeans. Some authors in the analysis of the different types of fever remedies have shown non-recommendedpracticesincare.TheobjectiveofthisworkbasedondatafromtheDemographicandHealthSurvey(DHS)wastostudythefactorsassociatedwithhealthcareuse inhealthfacilitiesforfeverinchildrenaged0to5years.

Methodologies:Thedatainthisstudyarefromthe2011-2012DHSofIvoryCoast.OurCrosssectorconsistedof1662childrenwhohadafeverinthelasttwoweeksbeforethesurvey.DataprocessingandanalysisweredonewithStata15software.Thedifferentstepsofthisanalysiswereaunivariateanalysisthatallowedustodescribethemainvariablesofthestudy.Thebivariateanalysis,theonlyoneofwhichwasp<0.05,allowedustoperformchi-squaretestsandtheCramer'sVtesttopreparethevariablestobeincludedinourlogisticregressionmodel.

Results: It was 1662 children who developed a fever during this period. Of these children, 38%receivedcareinahealthfacility.About68%ofchildrenfrompoorfamiliesdidnotreceivecareinahealth facility.Thewealth indexwasassociatedwithuseofcare (Pearsonchi2(4)=141.0878,Pr=0.000 and Cramer’s V = 0.2914). The Cramer’s V test between home environment and care useshowsthat47%ofchildreninthehomeenvironmentreceivedcareinahealthcarefacility(Pearsonchi2(1)=72.3671,Pr=0.000andCramer’sV=0.2087).Ontheotherhand,inruralareas73%didnotreceivecare.Religionwasalsoassociatedwithmoderateassociationstrength(Cramer’sV=0.1051,Pearsonchi2(2)=18.2992,Pr=0.000).Otherfactorssuchasregion,ethnicity,levelofeducationandexposuretomassmediawereassociatedwiththeuseofcare.

Conclusion:Healthpoliciesshoulddevelopstrategiestoraiseawarenessandimproveaccesstocareinahealthfacility,takingthesefactorsintoaccount.

Keywords:fever,healthfacility

Sustainable Financing for PHC: Designing a Contributory Health Scheme in Niger State, Nigeria

Dr.UsmanMohammed,NigerStateContributorySchemeAgency,Résultatspour l´InstitutdeDevelopment (R4D):Dr.ChrisAtim,TamaraChikhradze,EzinneEzekwem,OludareBodunrin,RachelNeill,FelixObiSystèmes de santé Consult Limited Health (HSCL): Oluwatosin Kolade, Onyeka Ojogwu, Ifeoma Kalu Igwe,NnamdiAnedoH.,MaimunaAbdullahiUniversitéduNigériaNsukka:Dr.HyacinthIchoku


Background: A Readiness assessment for UHC conducted in Niger State in 2017 showed theexistence of poor utilisation of PHC services and that majority of citizen lack access to qualityhealthcareduetolimitedpoolingandpre-paymentsystemsintheState.Pre-paymentsystemshavebeenrecognisedtoincreasefinancialprotectionaswellasimprovehealthoutcomes(WHOBulletin2012).Recognisingthis,NigerStateincollaborationwithResultsforDevelopment(R4D)andHealthSystems Consult Limited (HSCL) is designing a State Contributory Health Scheme (SCHS) forimplementation to ensure access to quality health services. This paper describes the processundertaken todesigna launchofacontributoryhealthschemewith focusonPrimaryHealthCare(PHC)andvulnerablegroups.

Keyobjectiveofthepaper:TopresenttheapproachadoptedbyNigerStateinthedesignofitsSCHSaswellaskeylessonslearnedinthedesignprocess.

Scheme DesignMethodology: R4D/HSCL and the state have adopted a number of approaches indesigning key components of the scheme (resourcemobilization, enrolment, strategic purchasing,M&Esystems).Thisincludes:quantitativeanalysistoidentifycostsandpotentialrevenueamountstolaunchscheme,adoptionofbestpracticestoguidedecisionsonprioritizationofschemecomponentsforinitiallaunchandscale-up,technicalreviewsofschemebilltoensurereadinessforpassageintolaw,establishmentofdesignTechnicalWorkingGroups(TWGs)andadesignfinalizationcommitteetoadvancetheschemedesign;provisionofon-the-jobmentoringandtrainingstobuildcapacityofNigerSCHSAgencystaffandkeystateactorsinhealthcarefinancing.

Key Lessons Learned Theinputofkeystakeholders(governmentagenciesandpartners)iscriticaltothedesignprocessasthis creates opportunities to leverage on existing systems and platforms e.g. the means testingapproachestoidentifypoorandvulnerable.

– Insettingswherea legal framework for theexistenceof thescheme“the law” isyet tobeestablished,theset-upofstrongstructuressuchasdesignTWGscanbevaluabletoadvancetheschemedesignandensurereadinesstolaunchwhenthelawiseventuallypassed.

– Continuousadvocacyandengagementwith thegovernment andother important actors iskey toensuringbuy-inon somekeydesigncomponents (e.g. resourcemobilization)of theSCHS.

– Lessons learned from fellow states, federal government schemes, and internationalexperiencesshouldbeleveragedtoadoptbestpracticesfromcountriesandstatesthathaveoperationalizedsimilarschemes.

Factors affecting access to healthcare and efforts/challenges in securing PHC

Ms.ChiomaB.Kanu,CivilSocietyLegislativeAdvocacyCentre(CISLAC) The Civil Society Legislative Advocacy Centre (CISLAC) has worked to improve policy environmentthatwillrevitalizethehealthsystemsince2012inmanyNortheastandNorthweststatesinNigeria.Thiswasachievedthroughengagementwithpolicymakers,legislators,civilsocietygroupsandmediaatnationalandsub-nationallevels.

The aims and objectives of the interventions are to improve financing for health by increasinglegislative oversight; to increase media reportage of health and to galvanize civil society actiontowardsadvocatingfortheimplementationofhealthpoliciesandlaws.

Thestrategiesfortheinterventionsincludeseriesofpolicydialoguesforexecutives-legislature-CSOs-media, advocacy engagements with policy makers and legislative arms of government, capacitybuilding on budget tracking and reporting for media and civil society on maternal health andnutrition.


From the multi-sectoral approach applied, it became obvious that the challenges facing PHC inNigeria are complex and essentially arising from poor legal, regulatory frameworks andimplementation,economic,socio-culturalchallenges,infrastructuraldecays,inadequate/unqualifiedhealth personnel and equipment. The situation of PHC worsens, as financial and politicalcommitmentsfromgovernmentarelacking;incaseswheretherehavebeenpronouncements,theyhavebeenpartiallyorentirelynotimplemented.

Therearemanyhealthprogramsbythegovernmentatnationalandsub-nationallevelsbutthebigquestionishoweffectivearetheseprograms?HowmanyNigeriansareawareoftheirexistenceandhowmanywomen in the rural communities access them?Thereareover24,000PHCsandhealthposts,scatteredallaroundthecountrywithintheruralareas.Healthworkerspostedtotheseareasare hardly available. There is no gainsaying that community people prefer the services ofunconventional community health workers, “chemists”, herbal mixtures and traditional birthattendants,becausethehealthfacilitiesareunsatisfactory.Ideally,PHCshouldbeaffordablebutincommunities where families live below the poverty line even the least fee is unattainable by thecommunity,whichbegsthequestionofUniversalHealthCoverageandbasichealthcarefunds.

In conclusion, health is on the concurrent list of the government. This signifies that if indeed thegovernment wants to pay attention to the prevalent health condition it can easily be achievedthroughseriousimplementationofhealthpoliciesandredeemingofpledgesatalllevels.

Non-farm employment for the rural poor and impact on health outcomes in Ghana: the role of social protection

IsaacOsei-Akoto,InstituteofStatisticalSocialandEconomicResearch(ISSER),UniversityofGhana,Legon

Addressingdisturbingpovertyandinequalitytrendsindevelopingcountriesrequireinnovativewaysofprovidingsecuredjobopportunitiesforthepopulace;mostimportantlyduringtheagriculturaloff-seasonsfortheruralpoor.Thiscouldbeachievedthroughsocialprotectionprograms,amongmanyotherstrategies.Activelabourmarketsocialprotectionoptions,ascomparedtootherssuchascashtransfers facilitate access of the most vulnerable to jobs, while reducing their dependence frompublic welfare support schemes. To this effect, the Labour Intensive Public Works (LIPW) of theGhana Social Opportunities Project (GSOP) was initiated in Ghana to provide targeted rural poorhouseholds access to local employment and income-earning opportunities during agricultural off-seasons. The program seeks to lessen the burden of unemployment or under-employment indeprivedruralcommunitiesduringtheleanagriculturalseasonwhilecreatingvitalinfrastructurefordevelopment of both farming and non-farming households. The study designed to evaluate theprojectassessedtheproject’simpactonlabourforceparticipationandemploymentforbothyoungmenandwomen,andtheirimplicationsforwelfareinmanyfarmingcommunitiesofGhana.

Thestudyuseddataon130community-level sub-projects includingmanualconstructionof feederroads, small earth dugout and tree planting to analyse the effects on broad aspects of rurallivelihoods. Quasi-experimental techniques, employing random assignment of sub-projects andapplicationofpropensityscorematchingwerethemajorestimationtechniquesused.

Theresultsshowsignificanteffectson labour forceparticipationandshort-termwageearnings forbothyoungmenandwomen.Additionally, thereweresignificant findingsonkeyhousehold issuessuchashealth,savingsbehaviour,farminvestment,andreversalofseasonalmigration.

This presentation highlights themixed results on how the use of social protection to improve theeconomicsecurityofpoorhouseholdsinfluencesaccesstohealthcare,foodsecurity,anduptakeofhealthinsuranceinGhana.Theprojectshadnosignificantimpactontheuseofhealthcarefacilitiesbut rather increased the use of self-medication. Some arms of the programme led to significant


reductionofenrolment into thenationalhealth insurancescheme,butotherarms in thesouthernpartofthecountryincreasedthecapacityofbeneficiariestoenrol.Thefindingsshedlightondesigneffectsandimplicationsforthesustainabilityofsuchinnovativeprograms.

Keywords:ruralpoverty,off-farmincome,socialprotection,healthinsurance,accesstohealthcareservices,gender,Ghana

Emigration of Nigerian Medical Doctors Survey

*IfeanyiNsofor,BellIhua,**HamzaKabir:*ABUJANigeriaHealthWatch,**NOIPolls

Background Emigration of Nigerian healthcareworkforce, particularlymedical doctors has been alingeringprobleminthecountry.Inabidtomeasurethescopeofthistrend,NigeriaHealthWatchinpartnership with NOI Polls conducted a survey onmedical doctors to assess the prevalence withwhichmedicaldoctorspursueworkopportunitiesabroadandprobablereasonswhy.

AimsandObjectivesTounderstandthescopeofemigratingdoctors,thefrequency,andsomeoftheunderlyingfactors.

MethodsThesurveywastargetedatNigerianmedicaldoctors,anditinvolvedamixedmethodologyapproachemployingquantitative andqualitativemethods. For thequantitativemethod, anonlinesurvey using a standardized, well-structured questionnaire was employed; and a semi-structuredinterview guide was utilized for the qualitative approach. The various cadres of doctors werecaptured inboththequantitativeandqualitativemethods.Respondentstotheonlinesurveywerenotlimitedbygeographicallocation,althoughthein-depthinterviewswereconductedwithmedicaldoctorsinNigeria’sFederalCapitalTerritory,Abuja.

Key findings A large proportion (83%) of doctorswho filled the survey and are based abroad arelicensed inNigeria.All respondents (100%) to the surveyknowmedicaldoctorswhoarepresentlyresidentinNigeria,whoarecurrentlyseekingworkopportunitiesabroad.Almost9in10respondents(88%)disclosedtheyareseekingworkopportunitiesabroad.

Mostrespondentscitedhightaxes&deductionsfromsalary(98%),lowworksatisfaction(92%),andpoor salaries & emoluments (91%) as challenges doctors face that make them consider movingabroad.TheUnitedKingdomandtheUnitedStatesarethetopdestinationswhereNigerianmedicaldoctorsseekworkopportunities.Prevalentreasonsforemigratingincludebetterfacilitiesandworkenvironment, higher remuneration, career progression & professional advancement, and betterqualityoflife.

Majority of survey respondents (87%) believe government is unconcerned with mitigating thechallenges facing medical doctors in Nigeria. Improved remuneration (18%), upgrade all hospitalfacilitiesandequipment(16%), increasehealthcarefunding(13%),and improveworkingconditionsofhealthworkerswerethetopsuggestionsrespondentsprofferedtomitigatechallengesdoctorsarefacing.

MainConclusionsTheissueofemigratingdoctorsisanimminentproblemasthefindingsfromthesurveyclearlyreveal.Alarmingly,majorityofrespondentswhoareresidentinthecountrydisclosedthat they are consideringwork opportunities abroad. This problem is a crisis consideringNigeria’srisingpopulationandgrowingdemandforhealthcareservices.

Do Facility-based Deliveries in Kenya adhere to WHO-recommended Guidelines for Post-Natal Care (PNC)?

GraceNjeriMuriithi,Associationafricained'économieetdepolitiquedelasanté(AfHEA)


BackgroundThepostnatalperiod(frombirthtosixweeksafterdelivery) isacrucialperiodfor thesurvival ofmothers and newborns. According to theWorld HealthOrganization, 66 percent of allmaternal deaths and 75 percent of all newborn deaths occurwithin the firstweek after delivery.Thereforeunderstanding the gaps inpostnatal care forwomen inKenya is important for ensuringthatthematernalandneonatalmortalityratesarereducedfurther.

AimsandobjectivesoftheresearchTheoverallaimofthisresearchwastoanalyzewhetherfacility-based deliveries in Kenya adhere to theWHO-recommended guidelines for provision of postnatalcare.

MethodsThestudymadeuseofdataobtainedfromthe2014KenyaDemographicandHealthSurvey(KDHS). A sample of children aged below 5 years who were born in a health facility was drawn(n=4,104). The variablesof interestwere check-upofmothers andnewbornsafterdeliverybeforedischarge.Datawasanalyzedusingdescriptivestatisticsandlogisticregressionmodels,whichwererun to evaluate the factors that influence the quality of postnatal care received by women whodeliverinhealthfacilities.

ResultsFromthedescriptivestatistics,30percentofthemothersstayedinthehealthfacilityforlessthan24hours,whileanadditional32.2percentstayedforadayandwerereleased.Only38percentstayedinthehealthfacilitiesformorethan24hours.Seventy-fivepercentofthemothersreceivedpost-natal check-upbeforedischargewhile 25percent didnot.Of thosewhodidnot receivePNCbefore discharge, only 12 percent received check-up after discharge. In total, 22 percent of thewomeninthesampledidnotreceivePNCatall.Ontheotherhand,69percentofnewbornsreceivedPNCinthetwomonthsafterbirth,while31percentdidnot.

Thelogisticregressionmodelsshowedthattheeducationlevelofthewoman,theplaceofdeliveryand number of antenatal care visits had statistically significant influence on postnatal check up.Specifically, womenwho had some education (whether primary, secondary or higher) weremorelikelytoreceivePNCthanwomenwithnoeducationatallandtheprobabilities increasedwiththeincrease in educational level. Women who delivered in lower-level public facilities had lowerprobabilities of receiving PNC compared to thosewho delivered in public hospitals;whilewomenwhodelivered inprivatehospitalsor clinicshadhigherprobabilitiesof receivingPNCcompared tothose who delivered in public hospitals. Women who received 4 or more ANC had higherprobabilitiesofreceivingPNCcomparedtothosewhoreceivedlessthan4ANCs.

ConclusionEnsuringthatwomeninKenyadeliverinhealthfacilitiesisnotenoughtoreducethehighmaternalandneonatalmortality rates.Thequality that thewomenandnewbornsreceivewhile inthe health facilities also matters. Policies should ensure that women and their newborns receiveadequatepost-natalcheck-upsbeforeandafterdischargetohelpaddresstheimmediatecausesofmaternalandneonatalmortality.

We assume they are gone : Traditional birth attendants as perceived deterrents to utilization of delivery services in Nigeria communities

Agbo,H.A1,2[MBBS,FWACP,MSC,MPH],DepartmentofCommunityMedicine,1JosUniversityTeachingHospital/2UniversityofJosCo-author:PamS[DipPHC]1 Introduction:Peculiaritiesareboundtonations/countrieswhereappropriateandavailableresourcesmaycometimelysuchas the introductionof traditionalbirthattendants intothehealthsystemtoidentifyandreferwomenwithriskoflikelybirthcomplicationstohealthcentres.ThispracticewaslaterabolishedbytheWorldHealthOrganizationwhenthedesiredbenefitsfromtrainingandusingthesehealthalliedwerenolongerbeneficialtomaternalhealth.


Theyhadseriesofhealthtrainingonbasicidentificationofatriskwomenandmanagementofsimplecases.Like ineveryaspect,outcomesaremeasuredagainst inputandthis isnoexceptionwiththetraditionalbirthattendants.Doweassumetheyhavebeenabolished?Wemaybewrong.Theyarerecognized in communities for their affordable services, timely and culturally acceptable practicesdespite complications that are often recorded.A study ofwomen assessing services at twourbanPrimaryHealthCare[PHC]centre,[NassarawaGwongandU/Rimi]wasconducted.

Aimsandobjectives:Prevalenceofhomedeliverywasobtainedandreasons fordeclininghospitaldeliverydespiteroutineantenatalcarevisitswereassessedasanindirectassessmentoftheactivitiesoftraditionalbirthattendants.

Methods:Crosssectionalstudyof215marriedwomengravidorparousirrespectiveofthedeliveryoutcomewhoassessed thePHC fromMay7th -18th 2018were studied.An interviewadministeredquestionnairewasused.

Findings:Onehundredandsixtyseven(77.7%)hadformaleducationtosecondarylevel.Eightythree(38.6%) registered and had uneventful antenatal care but did not assess the health centre fordelivery services. Of these that had they delivery attended to by a traditional birth attendant,31(37.3%),28(33.7%)and24(28.9%)didnotassessinstitutionaldeliveryduetoculturalpracticesforfirst delivery, enforced by spouse and in-laws and in order to save cost of hospital chargesrespectively.

Conclusion: The gains of routine antenatal care climaxed with institutional delivery should beencouragedthroughvigoroushealtheducationseriestowomen.Thismaylikelycurtailtheincreasingactofhomedeliverieswhichareoftenwithoutcomplications.

Achieving Universal Health Coverage in Nigeria: Do pecuniary factors matter?

Onwube,Onyebuchi,DepartmentofEconomicsandDevelopmentStudies,FacultyofManagementandSocialSciences,AlexEkwueme-FederalUniversityNdufuAlike,Ikwo.P.M.B1010Abakaliki,EbonyiState.Agwu,George,andIke,PreciousR.

Nigeria has adopted PrimaryHealth Care (PHC) as the anchor of theNigerian health system in itsefforts to improve equal access andutilization of basic health services and thus achieveUniversalHealth Coverage (UHC) for some forty years (1988 -2018) now. The approach has gone throughvariousimprovementsleadingtosomemodestachievements.YetNigeriaranksasthethirdleadingcountry in infantmortality rate in theworld (UNICEF 2017). This is in addition to the high rate ofmaternalmortality,unemployment,povertyandthedauntingeconomicrecession.TheobjectiveoftheresearchistogiveanarrativeofthefortyyearsjourneyintheprimaryhealthcareapproachtoachievinguniversalhealthcoverageandtoknowwhatfactorsarecriticaltostrengtheningthePHCapproach to achievingUHC inNigeria.Using a vector autoregressivedynamicmodel approach thestudy aims to determine the uniquepecuniary factors that can enhance health outcomes therebygiving credence to the primary health care approach to achieving universal health coverage foraccessingbasichealthcareservices.ThestudyfoundthatinNigeria,thefollowingpecuniaryfactors,publichealthexpenditureandpercapitaincomehavethecapacitytosustaintheprimaryhealthcareapproach toachievingUHC, through theireffecton improvedaccess tohealth servicesandhealthoutcomewhilehighratesof inflationandhighexchangerate lowersaccess tohealthcareservicesand thus limits the capacity of the primary health care approach to achieve the universal healthcoverage.Thestudy recommends thathealthexpenditurebe increased toensuresteadysupplyofhealthcareservicesandpercapitaincomeshouldbeincreasedinlinewithmacroeconomicrealitieswhile inflation and exchange rate should be effectively managed by the monetary authority toregulateitsfluctuationsandsubsequentdistortionoftheeconomywithimplicationsonhealth.The


studyconcludes thatprimaryhealth care remains thebestapproach toachievingUHC in so farasmembersofthesocietyfindshealthservicesavailable,accessibleandaffordable.

Impact of National Health Insurance Scheme Coverage on Catastrophic Health Expenditure in Ghana.

SandraKwakye,UniversityofGhana,SchoolofPublicHealth.Co-authors:DuahDwomah,PhD,JusticeNonvignon,PhD

Background: Ghana’sNationalHealth Insurance Scheme (NHIS)was designed to improve financialaccess especially amongst the poor, in the country’s bid to attain universal health coverage. Thescheme has been implemented since 2004 with the aim of providing financial protection tohouseholds therefore preventing payment at point of use of health services. The study sought todeterminetheimpactofNHIScoverageoncatastrophichealthexpenditure(CHE)amonghouseholdsinGhana.

Methods:DatawereobtainedfromtheGhanaLivingStandardsSurveyRound6(GLSS6),conductedin 2012-2013, with 16,772 households. CHE in this study was measured using 10% and 40%thresholds i.e. CHE was measured as household’s annual total out-of-pocket health payments(hospitalizationexcluded)equalingorexceeding10%and40%ofhousehold’snon-foodexpenditure.

Propensity scorematching was used to determine the impact of NHIS on out-of-pocket payment(OOP) and CHE. Multiple linear regression analysis was employed to determine the relationshipbetween covariates and OOP. Further, multivariate logistic regression analysis was used todeterminetherelationshipbetweencovariatesandCHEatboth10%and40%threshold.

Results:Thestudyfoundtheproportionofhouseholds incurringCHEtobe6.2%and0.3%for10%and 40% thresholds, respectively. NHIS coverage had a positive impact (p<0.05) on CHE at 10%thresholdbutnoimpactatthe40%threshold.

Conclusion:Thepositive impactofNHIScoverageonCHE implies that the financial riskprotectionobjectiveoftheschemeisbeingrealized,thoughatasmallmargin.

Key terms: Catastrophic health expenditure, out-of-pocket health expenditure, National HealthInsuranceScheme,Ghana.

Saving for health using local financial social networks. A case study of districts in Eastern Uganda

MutebiAloysius,ElizabethEkirapa,RornaldKananura,MosesTetuiMakerereUniversitySchoolofPublicHealth

Background:Financialconstraintsareoneofthefactorsthathinderaccesstohealthservices.Resultsfromthenationalhealthaccountsshowedthat49%ofhealthexpenditurewasmetbyhouseholds.Households incurcosts fortransportation, food,purchaseofmedicineandother suppliesthatmaynotbeavailableatthehealthfacility.MostoftheruralpopulationinUgandahasnoaccesstoformalfinancialinstitutionsbutagrowingmajoritybelongstosavinggroups.Thesesavinggroupscouldhelphouseholdssaveandinvestincomethatcouldbeusedtoreducefinancialbarrierstoservices.

Objectives: This paper seeks to describe the key characteristics of saving groups, benefits andchallengesofCommunityBasedSavingGroups(CBSGs),aswellassolutionstothechallengesinthequestofimprovinghouseholdhealth.

Methods: This was a cross sectional descriptive study with quantitative and qualitative datacollection techniques.Datawas collected from247CBSG leaders in thedistrictsofKamuli, Kibukuand Pallisa using self-administered open-ended questionnaires, qualitative interviews and from


project reports.Results:At thebaseline, themain reasons for the formationofCBSGswere to increasehouseholdincome,develop the communityand save foremergencies. Slightlymore thanahalfof the savinggroupshad15-30members.Ninety-threepercentoftheCBSGsindicatedelectingtheirmanagementcommittees democratically. The most common challenges associated with CBSG managementincludedhighilliteracy(35%)amongtheleaders,irregularattendanceofmeetings(22%),andlackoftraining on management and leadership (19%). It was noted in the intervention arms that thenumber of saving groups more than doubled from 431 to 915 between September 2013 andDecember2016.Outof915savinggroups,22%hadmemberssavingforMNH.

Conclusions: Saving groups in Uganda have the basic required structures and communities areinterestedinjoiningthecommunitybasedsavingsgroupsandsavingforhealth.However,challengesexist in relation to trainingandmanagementof thegroupsandmanagementof groupassets. Thegovernment and development partners shouldwork together to provide technical support to thegroups.

Keywords:Communitybasedsavinggroups,savingforhealth,localfinancialsocialnetworks

Exploring the relationship between Community-Based Health Insurance and Primary healthcare systems performance: Evidence from Nigeria

Ms.IBOROE.NELSON;PhDCandidate,DepartmentofEconomics,UniversityofUyo,AkwaIbomState,Nigeria

Background: Primary Health Care (PHC) is the backbone of a health systems and her strength isassociatedwithimprovedpopulationhealthinlowandmiddle-incomecountries.Thechronicunder-funding of theNigerian health system generally and primary health care in particular exacerbateshealth inequityandhampersefforts towardsuniversalhealthcoverage (UHC).Besides, it results inpoorserviceutilizationrateandhamperseffortstowardspoorhealthindices.However,mechanismsthatofferhealthsecuritythroughriskpoolinglikecommunity-basedhealthinsurance(CBHI)schemehasbeenimplementedacrossmostruralsettingsalbeitinrelativelysmallscaleasatoolinachievingequityinaccesstohealthservices.

ObjectiveandMethod:Thepaperseekstoassessthecontributionsofthe inputsandprocessesoftheCBHItothePHCsystemsperformanceusingasimple input-output logicmodelthat focusesonhealthfinancingandservicedeliverycapacityasinputandgovernanceandhealthserviceutilization(ANC,deliveryand immunization)asoutput.DatafromtwoCBHIschemes inAkwaIbomandRiverStates (pre-CBHI schemeandduring the scheme)wereused. Thiswas complementedby FGDandKeyInformantinterview(KII)onhealthworkers,communitystructuresandCBHIenrollees.

Results: The result of the analysis shows that antenatal clinic (ANC) attendance and deliveryincreased significantly over the six months period following commencement of the scheme andprogresses thereafter. Similarly, quality of care from the client perspective, together with theavailabilityofdrugsandequipmentatthecentrealsoshowedsignificantimprovement.Inadditional,theschemealsoengenderseffectivereferralmechanism.

Conclusion: CBHF holds huge potentials towards improving the population health in Nigeria andaccelerating efforts towards the achievements of UHC. Besides, it provides a good option toproviding health coverage for the informal sector when properly designed and owned by thecommunity.

Health Insurance and Out-Of-Pocket Payment In Malaria Case Management in North-western Cameroon


GwatTchonglaNazah,UniversityofBuea,Cameroon

Malariaremainsthemostimportantcauseofmortalityofpersons,especiallychildrenandpregnantwomeninAfrica.HealthInsuranceisawaytopayforhealthcare.Itprotectspersonsfrompayingthefullcostsofmedicalserviceswhentheyare injuredorsick.Theoverallobjectiveofthisstudy is toevaluatetheimportanceandeffectivenessofHealthInsuranceinfacilitatingthepaymentofmalariabills in the Bamenda Health District. This is a cross sectional study in which questionnaires wereadministeredto202respondents.Secondarydatawasobtainedfromhospitalregistersoffourhealthfacilities in Bamenda Health District. The datawas analysed to show that there is a less than 1%coverage and enrolment in health insurance schemes in the BMHO,which is very low. Thereforepeoplestillcovertheirentirecostformalariatreatment,andarenotopportunetosavesomemoneyfromtheirtotalexpenditureonmalariabills.Inaddition,theknowledgeofHealthInsuranceamongpersonsinBamendaHealthDistrictis90.09%,whichisgood,butthereislessenrolment,makingthescheme, not very effective when it comes to covering malaria treatment bills. Finally, with theestimatedcostofabout20434FrancsCFAmonthlyonmalaria,uninsuredpersonsarelikelytosaveless than insuredpersonsasabout75%of thebill is covered for insuredpersons.This isa seriouseconomic burden on patients, which pushes them to borrow money to cover cost always, usetraditionalmedicineandroadsidemedicineasawaytoevadecostofhospitaltreatment.

Keywords:Cameroon,Malaria,HealthInsurance,Out-Of-PocketPayment

PosterPresentation2 Analysis of the sources of health human resources losses in Ivory Coast

YapiApollinaire(1);KouakouKonanAuguste(2);BissoumaTaniaRenée(3);CodjiaLaurence(4);BadiéYao(5)(1)NationalInstituteofPublicHealth-Abidjan(2)UniversityofLorougnonGuédédeDaloa/CEDRES(3)WorldHealthOrganisation–Ivorycoast(4)WorldHealthOrganisation–Geneva(5)HumanResourcesDepartment

Introduction:Toachieveuniversalhealthcoverage(UHC),theproblemoftheshortageofpersonnelinvolved in theprovisionof careand social services in low-incomecountries shouldbeaddressed.However, there isasignificant lossofHHRfromtrainingtorecruitment.Thus,theobjectiveofthisstudyistocriticallyanalysethesourcesofhealthhumanresourceslossfromtrainingtoretention.

Dataandmethodologies:Theseresultsusethedatafromthesurveyconductedduringtheconductofthehealthlabourmarketstudy.ThesurveywasconductedfromMaytoJuly2016inacrosssectorof223healthfacilities,38specializedpublicandprivateinstitutionsand363healthsciencestudents.


A quantitative retrospective cohort was studied. It concerned students admitted to the scientificbaccalaureateseriesDandC in1997andfollowedupfromtheirrequestsforassignment inhealthsciencestrainingcoursestorecruitmentaspractitioners.

Aqualitativestudywasassociatedwiththisstudytofindouttheirmotivationsandthereasonsfortheirloyalty.

Results: 6% of baccalaureate holders enter the first year of the common core curriculum (EPSS),representing80%ofallbaccalaureateholderswhoapplyforthehealthsciences;

Medical and paramedical disciplines attract 8% of graduates against Law (36%), Science andTechnology(22%),Modernlettersdiscipline,LanguagesandArt(13%),Economics(11%)in2013;

16% of them are admitted to the second year, 74% of whom aremale and 26% female; 84% ofstudents who have validated the second year are in thesis. Among these PhD students whosupported 27%were recruited by the public sector. 36.88% of the physicians in the cohort wereassignedtothepublicservice.Theaveragewaitingtimebeforethefirstjobisbetween1and3years;thepercentageofdoctorswhohavemigrated(40%intermsofstockand18%inannual flow);theemigrationrateofnurses(16%);theimmigrationrateofdoctors(7%).

Conclusion:Theobservation is that the trainingsystemmustbeadjusted inorder tobetter targettheobjectivesassignedtothetrainedpersonnel.BettercollaborationalsobetweentheMinistriesofHigherEducation,CivilServiceandHealthwillallowforbetterHHRplanning.

Keywords:loss,Humanresources,IvoryCoast

The Economic Impact of Rheumatic Heart Disease (RHD) on the Health System of South Africa. A Cost of Illness Study.

AssegidHellebo.SchoolofPublicHealthandFamilyMedicine,HealthEconomicsUnit,UniversityofCapeTown,SouthAfrica.

Background:RHDisadiseaseofpovertythatisneglectedindevelopingcountries.TheconsequencesofRHDareincreasinglybecominghugeeconomicburdentothehealthsystemandconsecutivelythegovernment.DespiteRHDbeingpreventable,mostoftheRHDrelateddeathshappeninchildrenandworkingageadultswheretheeconomicburdenofprematuredeathishigh.Severalstrategieshavebeensuggestedtoadvancetheescalationofdiseaseseverityinordertoavoidmedicalcostincludingcostofsurgery.However,lackofadequateevidenceregardingthecostoftreatingRHDhashinderedtheneededdecisionsandinterventionstopreventRHDrelateddeath.

Aims andObjectives:Themainobjectiveof this studywas toevaluate theutilizationof resourcesandquantifytheannualaveragetotalcostrelatedtoRHDinatertiaryhospitalintheWesternCape,SouthAfrica.

Methods:Amixture of ingredients and step-down costing approacheswere used to estimate theannualcostofRHDcarefromhealthsystemperspective.Allcostswereestimatedin2017(baseyear)SouthAfricanRand(ZAR)and3%discountrateinordertoallowdepreciationandopportunitycost.Data on service utilization rates were collected using a randomly selected sample of 100 patientmedicalrecordsfromtheGlobalRheumaticHeartDiseaseRegistry(theREMEDYstudy),aregistryofindividualslivingwithRHD.Patient-levelclinicaldata,including,pricesandquantitiesofmedicationsandlaboratorytests,werecollectedfromGrooteSchuurHospital(GSH).Step-downcostingwasusedtoestimateprovidertimecostsandallotherfacilitycostssuchasoverheads.REMEDYandGSHdatawereaggregatedtoestimatethetotalannualcostsofRHDcareatGSHandtheaverageannualper-patientcostamongREMEDYparticipants.One-wayunivariatesensitivityanalysiswasconductedtodealwithuncertainty.


Results:ThetotalcostofRHDcareatGSHwasestimatedat$2,238,294(ZAR27million) in2017,with surgery costs accounting for 65% of total costs. Per-patient average annual costs, whichincludedoutpatientcare,medicalandintensivecareunit(ICU)care,catheterisationlabprocedures,andheart valve surgery,was estimatedat $4, 311 (ZAR52, 000)per-patient annually. The cost ofmedicationsandconsumablesrelatedtocatheterisationandheartvalvesurgerywerethemaincostdrivers.

Conclusions: Scaling up of primary and secondary prevention programs at primary health centresreducesfutureburdenontertiaryservices.ThereishighneedofresourceallocationeffortsrelatedtoRHDattertiarycentres,andthestudyprovidescostestimates for futurestudiesof interventioncost-effectiveness.

A Digital Labour and Delivery Solution (DLDS) for improved service provision

SarahKedenge1,ElizabethMwashuma1,CarolineGitonga1,AliceTarus1,AlbertOrwa1,CarolineKyalo1,EddineSarroukh1.1PhilipsResearchAfrica Background TheWorld Health Organization (WHO) advocates the partograph as the singlemostuseful tool formonitoring labourandreducing labourcomplications.Despite itseffectiveness,sub-optimalutilizationandpoorrecordingofpartographparametersduringlabourareamatterofgreatconcern for the quality of intrapartum care worldwide. The digital labour and delivery solution(DLDS) is a tablet-based solution envisaged to make monitoring of labour and delivery moresystematic and efficient as well as provide a tool for easy communication between health careprovidersinmaternitywithinandbetweenhealthfacilities.Theprimaryaimofthestudywastotestthe applicability, benefits, and limitations of the tablet-based DLDS in a low-resource healthcaresetting inKenyaaseffortsaremadetoachieveuniversalhealthcoveragewith increasedaccess toqualityservices.

MethodologyThestudywasdesignedasanopen-labelexplorationstudy,dividedintotwophases.Thefirstphaseinvolvedtheassessmentofthehealthcareprofessionals’useofthepartographasperroutine practice. The second phase involved both the use of the tablet-based solution and paperpartographs. The study was implemented in two sites within Kiambu County, namely: GithuraiLangataHealthCenterandRuiruSub-CountyHospital.

ResultsDuringphaseone,atotalof22midwivesweretrained.Theone-dayincludedarefresheronpartograph use and potential gaps and training on research ethics. The midwives consented 82pregnantwomen.Fromthepartographanalysis,majorityoftheparametersweredocumentedwithonlyfewwithminimalornoentry.Duringphasetwo,15midwivesfromphaseoneweretrainedontheapplicationandprovidedauserguideforreference.Themidwivesentereddatafor75pregnantwomen into the application. Their feedbackwasmainly positive with a largemajority stating thepartograph, history taking anddischarge summaries as themost exciting features. The applicationscored 65% on the system usability scale, highlighting the need for some feature changes. Theintegrationoftheplannedreferralmodulewashighlightedaskey.

ConclusionsThefindingsfromthisstudydemonstratetheneedforcontinuedsupportandtraininginensuring100%completenessofpartographparameters.Feedbackontheapplicationdemonstratedthatwithsomemodifications,theapplicationprovidesagreatopportunitytoimprovetheefficiencyandeffectivenessinthemanagementofpatientsduringlabouranddelivery.

Household cooking fuel choice and health effects in Ghana

LucyOfori-DavisAWOSHIE&John-BoscoDramani:KwameNkrumahUniversityofScienceandTechnology


According to the InternationalEnergyAgency,more than2billionpeopleworldwideareunable toaccessmodernandcleanfuelssuchaselectricity,LPGandbiofuelsandthus,resorttobiomass.Thisimplies that the choice of cooking fuel by households has serious effects on energy transition.Therefore,weexaminethedeterminantsofhouseholdchoiceofcookingfuelandtheeffectofthehouseholdchoiceofcookingfuelsonthehealthofchildrenunder five.Usingdatadrawnfromthe2014 Ghana Demographic and Health Survey, we estimate the determinants of cooking fuel bymeansofanorderedprobitmodelandthehealthimpactofcookingfuelapplyingtheprobitmodel.The results reveal wealth, the age, gender and education of the household head, size of thehousehold and the location of kitchen in the household to influence the choice of cooking.Furthermore,theanalysisprovidesevidenceonthenegativeeffectofsolidfueluseonhealth,whichimplies that the use of solid fuels is a major contributor to the incidence of acute respiratoryinfections inchildrenundertheageof five inhouseholdsthatusesolidfuels.Werecommendthatstrategiesthatareaimedatpovertyreductionshouldbeintensifiedtoaidthetransitiontocleanerandmodernfuelsandintensifyeducationandawarenessofthedetrimentaleffectsoftraditionalfueluseonhealthofwomenandchildren.

Securing PHC for all: Applying GIS to Evaluate Siting of New Primary Health Facilities in Eswatini

SiyabongaNdwandwe1, Katherine E. Battle2, NontokozoMngadi1, George Shirreff1, Bradley Didier1, SifisoG.Mamba31ClintonHealthAccessInitiatives(CHAI)Inc.2MalariaAtlasProject(MAP),UniversityofOxford3MinistryofHealth,KingdomofEswatini Background:ThegovernmentofEswatini,throughtheNationalHealthSectorStrategicPlan(NHSSPII2014-2018),hadsetaboldtargettobuildoneprimaryhealthcare(PHC)facilityineachofthefourregions every year. However, this goal has not been achieved due to funding challenges. As thegovernmentcontinuestoreceiverequestsfromcommunitiesfornewPHCfacilities,theprioritizationofsitesposesachallenge.Historically,theapprovalandsitingoffacilitieshasnotbeeninformedbyaquantitativeassessment.Thisanalysisproposeanapproachforassessingnewhealthfacilityrequestsbasedongeospatialanalysisofaccesstocareinordertooptimiseresourceallocationbyprioritizingconstructionoffacilitiesinareaswiththemostlimitedaccesstocare.

Methods:TheresearchteamusedArcGIStomapoutexistinghealthcarefacilitiesandroadnetworksacross Eswatini using data collected by the Surveyor General’s Office. Travel times to the nearesthealth facility were calculated using a cost-distance analysis that assumed speeds of motorizedtransportwithinstipulatedlimitsandmodesoftransportandwalkingspeedsspecifictotheterrain.Accessibility thresholds were set at 8km Euclidean distance, per WHO recommendations and 30minutes travel time per the literature. An additional cost-distance analysis was performed onproximitytomaternityservices,aproxyforspecializedservicesgenerallynotofferedatlowestlevelofhealthsystem.

Keyfindings:Themajorityofthepopulationlivesincloseproximitytoahealthfacility:98percentofhomesteads are less than 30 minutes from a facility whilst 73% are within an 8 km radius. Thegovernmenthas25pendingrequests;onlytwositesareidentifiedasneedingaPHCfacilityusingthe30 minutes threshold. Seven sites were identified using the 8 km threshold: five with pendingrequests and two without. Nine percent of homesteads are more than 30 minutes away frommaternityserviceswhilst51%arebeyond8km.Pooraccesstospecializedcareisconcentratedinthenorth-eastandsouth-westpartsofthecountry.


Conclusionsandrecommendations:Eswatinihasagoodnetworkofexistingfacilitiesthereforethegovernment does not need to build four primary health facilities per year to improve equitableaccesstohealthcareservice.However,PHCismorethanphysicalfacilities.Theevidencehighlightsaneedtorevisetheservicepackageofferedatfacilitiestoensureequitableaccesstospecificservicesmayserveasaninstrumentfortheministrytoadvocateformoreresources.

Education on the abortion law: implications for choice of place for abortion services in Ghana

Fred Yao Gbagbo, University of Education, Department of Health Administration, P. O. Box 25, Winneba .Ghana.

BackgroundTheGhanaianabortionlaw(Act29,sections58-59and67),wasmodifiedin1985(LawNo. 102of 22 February, 1985).Although abortion is not explicitly legal inGhana, someprovisionsmadeinthelawsuggestlegalitytoincreaseaccess.

AimsandObjectivesThisstudyexploredEducationontheabortionlawandimplicationsonchoiceofplaceforabortionservicesinGhana.

MethodsThestudywasconductedinAccrametropolis,mostdenselypopulatedurbanmetropolisinGhanabetweenJanuaryandDecember2010usingretrospective,cross-sectional,communitybaseddesignandmixedmethodapproachtocollectdatafrom401randomlysampledwomeninJanuary-June2011.DataanalysiswasdoneusingSPSSandSTATAtotestthehypothesisofthestudyandchi-squaretestforthesignificanceofassociationsobserved.Qualitativedataobtainedwereparaphrasedand/orpresentedverbatimtocomplimentthequantitativedatacollected.TheGhanaHealthServicegaveethicalclearanceforthestudy.

Key Findings There was < 50 percent awareness the abortion law with about 43 percent of therespondentsreportingthatabortionwaslegalinGhana.Therewasasignificantassociationbetweeneducational attainment and knowledge about legal status of induce abortion among respondentswho had secondary and higher education (x2=16.977; p=0.009). About 9 percent of respondentsindicated that abortionwas legal but did not correctly indicate any of the legal provisions for anabortion in Ghana but rather gave socio-economic justifications for abortion. There were nosignificantassociationbetweenknowledgeoftheabortionlawandrespondents’choiceofplaceforabortion.Amultinomiallogisticregressionshowsthatrespondentswhoattainedatleastsecondarylevel education were 2.7 (p<0.05) significantly more likely to know the legal status of abortioncompared to those without any formal education. Less than 2 percent of respondents gave anaccurategestationperiodforlegallypermittedabortionand72percentindicatedthatabortionwaslegalstatedthatsomebody’sconsentisalwaysrequiredpriortoanabortion.Opinionsfromthein-depth interviewsshowedvariations indecisionsonplace foranabortionwithoutconsidering legalimplicationsfortheirchoiceofplace.

Conclusion Educational attainment impacts on understanding the abortion laws of Ghana fordecision making on choice of place for services. Although facilities could be legally mandated toprovideabortionservices, legalmandatesalonedonothavesignificant implicationson individuals’choiceofplaceforinduceabortioninGhana.

Health shocks in Sub-Saharan Africa: are the poor and uninsured households more vulnerable?

Esso-HanamATAKE,UniversityofLome(Togo),DepartmentofEconomics.


Background:Indevelopingcountries,healthshockisoneofthemostcommonidiosyncraticincomeshockandthemainreasonwhyhouseholds fall intopoverty.Empirical researchhasshownthat inthesecountries,householdsareunabletoaccess formal insurancemarkets inorderto insuretheirconsumptionagainsthealthshocks.Thus,inthisstudy,arethepooranduninsuredhouseholdsmorevulnerable from health shocks? We investigate the factors that lead to welfare loss from healthshocks, and how to break the vulnerability from health shocks in three Sub-Saharan Africa (SSA)countries,namely,BurkinaFaso,NigerandTogo.

Method: This study focusses on 1,597households in Burkina Faso, 1,342households inNiger and930householdsinTogo.Athree-stepFeasibleGeneralizedLeastSquares(FGLS)methodwasusedtoestimate vulnerability to poverty and to model the effects of health shocks on vulnerability topoverty.

Results:Theestimatesofvulnerabilityshowthatabout39.04%,33.69%,and69.03%ofhouseholdsarevulnerabletopoverty, inBurkinaFaso,Niger,andTogorespectively.Bothinteractionvariables,‘health shocks and wealth’ and ‘health shocks and access to health insurance’ had a significantnegative effect on reducing household’s vulnerability to poverty. Poverty is the leading cause ofeconomiclossfromhealthshocksasthepoorercannotaffordthepurchaseofsufficientquantitiesofquality food, preventive and curative health care, and education. We found that lack of healthinsurancecoveragehada significanteffectby increasing the incidenceofwelfare loss fromhealthshocks.Moreover,householdsize,typeofhealthcareused,gender,educationandageoftheheadofthehouseholdaswellasthecharacteristicsofhousingaffectvulnerabilitytopoverty.

Conclusion:Ourfindingssuggestthatforthepoorhouseholds,reductionofuserfeesofhealthcareatthepointofserviceorexpansionofhealthinsurancecouldmitigatevulnerabilitytopoverty.Otherchallenges—birth control policy, adequate sanitation facilities and a universal basic educationprogram—need to be addressed in order to reduce significantly the effects of health shocks onvulnerabilitytopovertyinSSA.

Keywords: vulnerability to poverty, health shocks, health insurance, poverty, fertility, sanitation,education,Sub-SaharanAfrica.

The effects of child mortality and income on fertility in Ghana

Mr.WilliamAngko,UniversityforDevelopmentStudies

Using data from the 2014 Ghana Demographic and Health Survey, we apply the conventionalmicroeconomictheoreticapproachtoconsumerchoiceandmodelademandfunctionforchildreninorder to estimate the effects of child mortality and income on the demand for children amongwomen of reproductive age 15-49 in Ghana using the negative binomial regression. The resultsindicatethatchildmortality,resultingfromthelossofasonordaughterhasapositiveandsignificanteffecton fertility,while fertility fallswith increasingwealth. Inaddition, theageofwomenat firstbirths,mother’syearsofeducationandcontraceptiveusearesignificantandnegativelyassociatedwith fertility, while current age of the woman, fertility preference, and decision maker oncontraceptive use and place of residence positively influence fertility in Ghana. We recordedvariations in the effects of some variables in total, urban and rural samples. We conclude thatreduction inchildmortalityand improvement inwealthcancontributesignificantlytothequesttoreducefertilityinGhanainordertokeeppopulationgrowthincheckandtoenhancethegrowthofpercapitaGDP.Increasingwomenaccessofformaleducation,increasingwomenpowerindecisionmaking on contraceptive use, increasing access to and use of contraceptives and providingemployment opportunities in rural areas are keys policy issues that could help achieve fertilityreductioninGhana.


Keywords:Childmortality,Income,Fertility,Demandforchildren

Factors influencing demand for health insurance in Uganda

SsempalaRichard,MakerereUniversitySchoolofPublicHealth

ThisstudyappliesaprobitmodeltosecondarydatatoinvestigatethefactorsinfluencingdemandforhealthinsuranceinUganda.Theresultsrevealthatwealth,levelofeducation,accesstoinformationandareaofresidencearesignificantlyassociatedwithdemandforhealthinsurance.However,age,marital statusandhealthstatusasproxiedbysmokingare insignificant.Results furtherreveal thathealthinsuranceismorepronouncedamongwealthier,educatedandwell-informedindividualswhoreside in urban areas. The study therefore recommends for the policies geared towards povertyreduction, investing ineducationbothatprimaryandsecondary levels, increasedpublicawarenessaboutbenefitsofhealth insuranceandestablishmentofaNationalSocialHealth insuranceschemesincesuchvariableswerehighlyassociatedwithdemandforhealthinsurance.

How to cope with food price shocks? – Assessing children’s nutritional status using biomarker data from Tanzania.

LukasKornher,CenterforDevelopmentResearch,UniversityofBonn

Surges in staple foodprices regularlydistressagrariansocieties inAfrica. InTanzania,maizepricesdoubled in 2008 and again in 2017 within few months. Whenever staple food prices increase,households make use of food based coping strategies of affected households include shifts fromexpensivetocheaperlesspreferredfooditems,areductionofdietarydiversitytowardsenergy-richproducts, andageneral reductionof thequantity consumed;either forall householdmembersoronlysomemembers(Matzetal.,2015;d’SouzaandJoliffe,2014).

Yet, depending on the adjustment behavior, the price shock can lead to severe macro andmicronutrient deficiencies of children, which are associated with adverse consequence for theirphysicalandmentaldevelopment.Theobjectiveofthisresearchtoassesstheimpactofstaplefoodpriceinflationontheshort-termnutritionalstatusofchildrenbetween0to60months.Therebythestudy utilizes a unique biomarker data set as part of the Tanzanian DHS 2010. The study fills aresearchgapintheexistingliterature(e.g.AbdulaiandAubert,2004)bylookingatmicro-nutritionalindicators,namelyweight-for-age,retinol-bindingprotein forvitaminA,andthesolubletransferrinreceptorasamarkerofironstatus,directlyinsteadofnutrientconsumptionlevels.

Theempiricalidentificationmakesuseofthetimelyandspatialvariationofstaplefoodprices,whicharematchedwith themicrodataat the sub-regional level. Toaccount for the serial correlationofstandard errors across equations, Zellner’s seemingly unrelated regression equations model isemployed.Preliminaryfindings,controllingforsocio-economicandbiologicalcharacteristics,suggestthat there isa significantpositiveassociationbetweenstaple foodprice inflationandchildren’saswell as women’s iron deficiency. On the other hand, weight-for-age seems unrelated to the foodprice level,whilewomen’sbmi isrelatedtostapleprices inflation.Surprisingly,thelevelofretinol-bindingproteinforbothchildrenandwomenispositivelyassociatedwiththepricelevel.

Dietarydiversityandmeatconsumptionreduceswithincreasingstaplefoodprices,butthereisalsoempirical evidence for a substitution of staples by diary products. The differential impact of foodpricesonwomenandchildren,canbeasignofmaternalbuffering,whichisthereductionofcaloricintakeofmothersinfavoroftheirchildren.Theresultsindicatetheimportancetowidenthepolicy


focus beyond staple food crops. Further, it is important to better understand substitution andincomeeffectswhenstaplepricesrise.

Direct and spillover effects of health insurance on household consumption patterns in Ekiti state, Nigeria.

FrancisO.Adeyemi,DepartmentofEconomics,UniversityofIbadan, The twin issues of resource and poverty distribution in Nigeria are paradoxical. This is because,though the country is rich in natural, land and human resources, Nigerian people are still beingdescribed as poor. This is confirmed by the report of national bureau of statistics that nearly 70percentofNigeriansasat2017werelivinginpovertyusingdollarperdayadjustedpurchasingpowerparity as the criterion.Thisimpliesweak ability to smoothen consumption over time for a largepercentage of the populationwhenever there is ailment. Previous studies had investigated directeffectofhealthinsuranceonmedicalconsumptionwithnoattentiontothespillovereffectsonnon-medicalconsumption.Thisstudyistherefore,designedtoexaminethedirectandspillovereffectsofHIonbothmedicalandnon-medicalconsumptioninEkitiState.

The survey research design was employed and purposive sampling technique was used to selecthospitals that offer health insurance services across the sixteen local government areas (LGAs)ofEkitistate.Astructuredquestionnairewasrandomlyadministeredto95patientsperLGA.

Diagnostictestwasperformedtoshowthequalityofmatch between the insured and uninsuredhouseholds,and their suitability for the study.The propensity score from logit regression at ρ/≤/0.05 was used to predict the probability of HI participation, while propensity score matchingestimatorwasusedtodeterminethedirectandspillovereffectsofhealthinsurance.

Theaverageageof the respondentswas43 years; about 69%weremarried; 76%and50%of thefamily heads had post-secondary education and were government employees respectively. Thereduction in the value of Pseudo-R2 and Mean bias from 0.17 to 0.01 and from 72.4 to 17.9respectively showed high quality of match between the two groups and this underlined theirsuitability for the study.The propensity score matching coefficient for medical consumption was0.07andpositive,showingthatmedicalconsumptionincreasedwithhealthinsurancestatus.The

spillovereffectofHIwas24,970anditwaspositive(+)indicatingthathealthinsuranceincreasednon-medicalconsumptionoftheinsuredbyN24,970intheperiodofillness.

ThisimpliesthathealthinsuranceincreasedtheoverallconsumptionoftheinsuredhouseholdsintheState.

Keywords:Directeffect,Spillovereffect,PropensityScoreMatching,Consumptionpatterns,

Implementation of a Mental Health Act in Ghana: A study of potential barriers and enablers using a mixed-method approach

KennethA.Ae-Ngibise1,2*,MichaelHazelton2,ChrisKewley2,DavidPerkins2,KwakuPokuAsante21UniversityofNewcastle,Australiaand2KintampoHealthResearchCentre,Ghana Background:TheWorldHealthOrganisationestimatethatmorethan450millionpeopleworldwideare suffering frommental health disorders. Low and middle-income countries are badly affectedpartly because they are ill-equipped to addressmental health needs due to lack ofmental healthpoliciesandmoreimportantlyenforcementandimplementation.Theprevalenceofmentaldisordersin Ghana is estimated at 13% with very limited mental health services available. In 2012, Ghana


passed aMental Health Act 846 to promotemental health care delivery. There is no evidence ofimplementation post-enactment. Previous mental health laws have never been implemented inGhana, resulting in wider human rights abuse and many seeking alternative treatment fromtraditionalandfaith-basedpractitioners.

Aim: This research seeks to assess organisational barriers and enablers for implementation of the2012MentalHealthActacrossGhana.

Methods:Mixed-methodresearchusingbothqualitativeandquantitativedatacollectiontechniqueswouldbeused.Qualitatively,face–to–faceinterviewsandFocusGroupDiscussionswillbeconductedwith a representative key stakeholders across all ten regions of Ghana to assess the barriers toimplementation.Quantitatively,therewillbeasurveyofpeoplewithseverementaldisordersintheKintampoNorthMunicipalitytomeasuredisability.The12-itemWorldHealthOrganisationDisabilityAssessmentSchedulewillbeusedtoassessthedisabilityfunctionalityofpeoplewithseverementaldisorders,andtheirexpectationofmentalhealthservicedelivery.Inaddition,abriefsurveywillbeconductedtoassesstheprogressofimplementationoftheMentalHealthActfromtheperspectivesofmentalhealthserviceusersandcommunitymembers.

AnticipatedFindings:Therewillbeabroaderperspectiveofevaluatinganddocumentingthebarriersand enablers for a full-scale implementation of the Mental Health Act in Ghana. The study willexplorehowbesttoaddressthecomplexpractice-interfacebetweentraditionalpractitioners,faith-based practitioners and main stream mental health services within a regulated and statutoryenvironment and recommend their integration into the formal mental health delivery system.Baselinedata isexpectedtobeestablishedforfuturemeasurementof implementationprogressoftheAct.Aboveall,thisstudywillcreatestakeholderawarenessandreinforcementofhumanrightssurveillanceandprotection.

Conclusion:TheMentalHealthAct846of2012made important steps in recognising theneed fordignified,all-inclusivetreatmentofmentaldisorders.Nonetheless,noplans,regulations, incentivesandfinancingmechanismshavesofarbeencreatedtoensuretheActisimplementedproperly.

Examining existing economic and political dynamics towards achieving universal financial risk protection in Enugu State southeast Nigeria.

IfeyinwaArize1,,ChikezieNwankwor1,andObinnaOnwujekwe11DepartmentofHealthAdministrationandManagement,FacultyofHealthSciencesandTechnology,CollegeofMedicine,UniversityofNigeriaNsukka,EnuguCampus.

Background: Moving towards universal health coverage (UHC) requires political and economicinputs. The general consensus on health system financing is that it should not only seek to raisesufficient funds for health, but should do so in a way that allows people to use needed serviceswithoutincurringfinancialrisk.Despitesubstantialincreasesinexternalassistanceforhealthinmostlowandmiddle incomecountries (LMIC) likeNigeria,out-of-pocketexpenditure remains incrediblyhigh(95.3%in2013)inNigeria.

Objective: The objective of this study is to examine political and economic factors that enable orconstrain achievement of universal financial risk protection through the opinions of Keystakeholders.

Methods: The study was conducted in Enugu State, South eastern Nigeria. Enugu State in 2004adoptedandimplementstheDistrictHealthSystemApproachtohealthcaredelivery.Weemployedacrosssectionalstudydesignandqualitativemethod(In-depth-Interviews)incollectingdataforthisstudy.Purposivesamplingofoneurban(EnuguNorth)andonerural(EnuguEast)localgovernmentareaswasadopted.Datawerecollectedthroughin-depthinterviews(n=17),anddocumentreviews


(policy and regulatory documents). We purposively sampled respondents from the Ministry ofHealth, State Health Board, State Primary Health Development Agency, cottage hospitals, PHC,HouseofAssemblyCommitteeonHealthandNHISdeskofficer.

Findings: Political factors that enable achievement of universal financial risk protection includedpolitical will, commitment and political stability. On the citizen’s side, their voice is usually notconsideredintheaffairsofrunningthepolity,whichinevitablyleadstotheirrightsbeensidetracked.Findings also showed that poor prioritization of health on government agenda, was inimical toachievingUFRP.Themajoreconomic factor that constrainedachievingUFRPwaspoor fiscal spaceforhealth.

Conclusion:Poorprioritizationofhealth ingovernmentagendaandpoorfiscalspaceremainmajorobstacles in achieving universal financial risk protection. Continuous and objective engagement ofcitizensandotherstakeholders inthepolicydialogueshouldbeincreasedandencouragedtobringUFRPontopofgovernment'sagenda.Itisalsonecessarytoinvolvecommunitystakeholdersasvoiceofthepeopletoparticipateinthepolicydebatetoforcegovernmenttogivehealthitsduepriorityinthewideagendaofcateringforthecitizens.

Acknowledgement:TETFUNDUniversityofNigeriaNsukka

Perspectives of women and health professionals on the benefit package for free maternal health services under the National Health Insurance Scheme of Ghana.

AlexanderSuukLaar1,SylvesterIsang2,BenjaminBaguune3,EmmanuelBekyieriya41UniversityofNewcastle,SchoolofPublicandMedicine,FacultyofHealthandMedicine,Australia.2GhanaSchoolofLaw,KwameNkrumahUniversityofScienceTechnology,Kumasi,Ghana3SchoolofHygiene,EnvironmentalHealthProgramme,MinistryofHealth,Tamale,Ghana4REJInstitute,ResearchandICTConsultancyServices,Ghana.

Background: To ensure equity in healthcare delivery for all residents of Ghana and ensuring anacceptable quality package of essential health care services without out-of-pocket payments; thegovernmentofGhanaimplementedUniversalHealthCoverageundertheNationalHealthInsuranceScheme(NHIS) in2005.Toimprovefinancialaccesstomaternalhealthservices,freematernalcareexemptionpolicywasalsoimplementedin2008.

Aim:Thisstudyexploredtheviewsofwomenandhealthprofessionalsonthecomprehensivenessofthebenefitpackageofthefreematernalhealthpolicyformaternalhealthservices.

Methods:Aqualitativestudycomprisingof6FocusGroupDiscussions(FGDs)and10Keyinformantinterviews(KIIs)wereconductedwithwomenandhealthprofessionalsinthreeruraldistrictsintheUpperWestregionofGhana.Interviewswereaudiorecordedandtranscribed.Datawereanalysedusingthematicframeworkapproach.

Results:Thefindingsshowedthatreproductivehealthservicesuchasfamilyplanningwasnotpartofthebenefitpackage.BothFGDsparticipantsandKIIsexpresseddissatisfactionofthecurrentbenefitpackagenotincludingfamilyplanningservices.Theywereemphaticthatthebenefitpackagecannotbecomprehensiveandequitableiftheseserviceswerenotpart.Someparticipantswereoftheviewthatitisbecauseofthemoneywomenhavetopaytoaccesstheseservicesthatismakingthemtoavoid using them. They also think that thepolicymaynot be adequately addressing thematernalhealthneedsofwomeniffamilyplanningserviceswereleftoutofthebenefitpackage.Participantsunanimously agreed that it was essential for policy makers to begin considering making familyplanningservicespartofthepackageofthepolicytomeetwomenneedsonplanningtheirfamilies.

Conclusions: Our study has identified cost as one of the reasons for non-use of family planningservices in rural Ghana. To ensure universal access to sexual and reproductive health services is


critical due to its multiple health and social benefits. For Ghana to achieve the sustainabledevelopment goal 3 target by 2030, requires policymakers and implementers to considermakingfamilyplanning servicespartof thebenefitpackageof the freematernalhealthpolicy to improveaccessbypoorruralwoman.

Key words: National health insurance scheme, universal health coverage, women, healthprofessionals,Ghana.

PosterPresentation3 Evaluation of sustainable surgical training for clinical officers in Malawi

JakubGajewski,EricBorgstein:DublinInstituteofGlobalSurgery,RoyalCollegeofSurgeonsinIreland

Background: Shortages of specialist surgeons in African countries mean that the needs of ruralpopulations gounmet. Task-shifting from surgical specialists toother cadresof cliniciansoccurs insomecountries,butwithoutwidespreadacceptance.ClinicalOfficerSurgicalTraininginAfrica(COST-Africa)developedandimplementedBScsurgicaltrainingforclinicalofficersinMalawi.

Methods: 17 trainees participated in the COST-Africa BSc training 2013-2016. This matched-pairsstudy done in 16 hospitals compared crude numbers of selected numbers of major surgicalprocedures between intervention and control sites before and after the intervention.VolumeandoutcomesofsurgerywerecomparedwithininterventionhospitalsbetweentheCOST-Africatraineesandothersurgicallyactivecadres.

Results: The volume of surgical procedures undertaken at intervention hospitals almost doubled(+89%, 2013-2015), and there was a slight reduction in the number of cases done in the controlhospitals(-4%,2013-2015),(p=0.059).IntheinterventionhospitalsmostgeneralcasesweredonebyCOST-Africatrainees(61.2%)comparedtootherClinicalOfficers(31.3%)andMedicalDoctors(7.4%).PostoperativewoundinfectionratesforherniaproceduresatinterventionhospitalswerecomparedbetweentraineesandMedicalDoctorswithnostatisticaldifferencefound(p=0.065).

Conclusion:COST-Africadeveloped,implementedandevaluatedMalawi’sfirstpostgraduatesurgicaltrainingprogrammefornon-physicianclinicians.Thetrainingmodelhasprovedtobeeffectiveandhas been embeddedwithin themainstream educational programmes offered by theUniversity ofMalawi’sCollegeofMedicine.However,thereareseriousrisksendangeringthelongtermsuccessofthe model, including the absence of career paths for COs in Malawi after obtaining the BSc inSurgery,whichissimilartothesituationofotherNPCsintheregion.

Comparative costing analysis of Primary Health Care: PPP-PHC model vs traditional PHC model

Alice Tarus1*, Vincent Okungu1, Boniface Oyugi2, Caroline Gitonga1, Sarah Kedenge1, Caroline Kyalo1, AlbertOrwa1,EddineSarroukh11PhilipsResearchAfricaHub2CentreforHealthservicesstudies,UniversityofKentCT27NFEngland


Background:ThegoalofUniversalHealthCoverage(UHC)istoensureaccesstoaffordable,equitableandqualityhealthservicesforallby2030andisatthetopofglobalhealthpolicyagenda.Whilstnoclearblueprint toUHCexists, there is renewedemphasisonprimaryhealth care (PHC)as a viableapproach to achieve UHC. Because of the cost implications, progress to UHC would requiresinvolvement of the private sector through partnerships such as public-private partnerships (PPP).Partnershipshavebeenshowntoimproveefficiency,reducecostsandincreasevalueinhealthcare.PhilipsthroughcollaborationwiththecountygovernmentofKiambuinKenyasetupfirstofitskindPPP-PHC intervention in 2014, Community Life Centre (CLC), to address access to care, qualityoutcomesandefficiencyof care in low-resource settings.Aspartof the collaboration, theKiambuCounty has been carrying out routine monitoring and evaluation of health indicators, revenue,expenditureandstaffingwithsupportfromPhilips.However,therehasnotbeenacostinganalysisofthe PPP-PHCmodel compared to a conventional county runmodel. Therefore, this study seeks tounderstand the value-add of a PPP-PHC model through comparative costing analysis of the twomodels.

Methods: The study employed activity-based costing. Direct and indirect cost were allocated torespective cost centres including direct materials (drugs and consumables), direct and indirectlabour,overheads,andpropertyandequipment.

Results:Initialresultsshows,intheinitialphaseofthepartnership,thecostpercapitaformaternalserviceishigherinthePPP-PHCmodelthanintraditionalPHCduetothehighcapitalinvestment.Atthestartofthepartnership,thereimbursementtoPPPfacilitywasmorethantheexpenditureuntillate 2016 where expenditure exceeded revenues. However, health expenditure by the non-PPPfacilityisconsistentlyhigherthantherevenuesthroughoutthestudyperiod.

Conclusion:ThePPPwasformulatedonthepremiseoncreatingavalueadditioninhealthcarewitha view to achieving UHC. While the results show that revenues and expenditures of a PPP aresignificantly lower than the non-PPP models, full results from the costing study will be used tocontribute to the current discourse on role of PPPs in achievingUHC.While the PPP could createdemand for service, there is further need to understand their role in achieving efficient healthsystemsinsuchlow-incomesettings.

Determinants of use of skilled attendants at birth in East Gonja district of the Northern Region

KipoBiiBole,UniversityofGhana

Introduction: Inthe late2003,GovernmentofGhana introducedapolicyexemptingwomeninthefourpoorest regionsof thecountry (Northern,UpperEast,UpperWestandtheCentral)attendingpublicandprivatehealthfacilitiesfrompayinguserfeesfordeliverycare.

Thestrategyintendedtogethighlevelsoffacilitydeliveryandtherebytolowermaternalmorbidityandmortality.Inyear2005thestrategywasincreasedtotheremainingsix(6)regionsofthecountry(Bosu et al, 2007). Despite this free delivery care policy, the East Gonja District still records lowskilledattendantsatbirthofabout37.9%withmaternalmortalityof3per1000livebirth(EastGonjaDistrictHealthDirectorate,2016).

Objectives: The study examines the association ofmaternal factors, access to reproductive healthservices,socio-culturalfactorsandtheuseofskilledattendantsatbirth.

Methods:Theresearchapproachwasquantitativeapproach.Icarriedoutprimarydataanalysisofacross sectional study design. A purposive sampling technique was used to interview 345 eligiblemothers’ respondents (15-49years),whohadchildren less thanoneyearofageprior to thestudy.


CollecteddatawerecodedandsummarizedusingexcelandexportedintoSTATAandSPSS14.1foranalysis.Multivariablelogisticregressionmodelwascarriedout.Adjustedoddsratio(AOR)andtheir95%confidenceintervalswerecalculated.Pvaluelessthan0.05wereconsideredsignificant.

Results: Among the mothers who were interviewed of their last birth, 37.97% (n=131) weredelivered with skilled birth attendant while 60.87% (n=210) were delivered with unskilled birthattendants. Attending ANC was equally important, 92 (26.67%) women attended ANC duringpregnancyand253(73.33%)didnotattendANCduringpregnancy.

Conclusion: Less than 40% of women deliver with skilled birth attendants (that’s 37.9%). Thewoman’seducationallevel,herpartnerlevelofeducation,ANCattendantsandoccupation,culturalfactors,parityareassociatedwithawomanaccessingskilledattendantsatbirth.

Keywords:Skilledattendants,Delivery,Birth,Maternalhealth,Obstetriccare,EastGonjaDistrictandAntenatalcare(ANC).

The role of partners in negotiating pre payment for maternal and child health services

MwanaidMlaguzi,InstitutSanitaired’Ifakara

IntroductionForyears,therehasbeenpoorcooperationinpreparationforaccessinghealthservicesin a number of communities in developing countries. A number of influencing scholar looking onways to improve quality and behavior change that will facilitate utilization of maternal healthservicesadvocatedtheneedtoincooperatemanonreproductivehealth.

From 2010 the national health insurance fund (NHIF) implemented a program covering heathservices for pregnant women and later covers a family of a womenwith community health fund(CHF)forayearindistrictofTangaandMbeyaregion.Theintensionwastorisewomenpurchasingpowerwhenseekingmaternalandchildhealthservicesduringpregnant,deliveryandafterdelivery.TheprogramwasdesignedtoinvolveamaninaccessinghealthservicesandlateradvocatetheCHFenrolment.

Methodology The study team performed indepth interview with male partner, focus groupdiscussionwith female partnerwho benefited frommaternal and child health pre paid insurance.Alsotheteamconductedgroupdiscussionwithhealthprovidersatcommunity(CHW),atdispensary(facility incharge and nurses) at health centre with facility incharge and nurses working onreproductiveandchildhealthunit,athospitalwithnursesworkingonreproductiveandchildhealthunitandatmanagementleveltheteamconductedgroupdiscussionwithdistricthealthmanagementteam, regional management team and national health insurance team responsible onimplementationoftheprogram.

ResultTheresultdepictthattheallpregnantwomenatatimeoftheprogramwereenrolled.Notallwomenwere able to receive the CHF card on time. The reason behind ismost of themwere notaware that theywere enrolled in a program offering a free services at a time they are pregnant,duringdeliveryandafterdeliveryherhousehold iscoveredbyCHFforayear.Forthosewhowereaware, some failed tohave theCHFas theydidnotbroughtpictures for their family on timeandothersweresinglemothers,sotheydidnotseemotivetoenrollothermembers.

Anumberofmaleclaimedthattheywerenotawareoftheprogramandiftheirwifewereenrolledintheprogram.

Conclusion There is a need to intensify community sensitization on the implementation of theprograms. Partners involvement negotiatingmaternal health services pre payment and utilizationincreasescommitmentandmotivesofmalespartnerontheirwivesandnewborns.


Performance Based Financing: A Qualitative Assessment and Cost Implication on burden on Disease in Cameroon

OkwenPatrick,AnendamLarinet:BamendaEffectiveBasicServices

Background: Cameroon is lowermiddle-income countrywithmodest resources.Despite increasedspending in health, healthoutcomes are still progressing very slowly andCameroon is still laggingbehindkeySDG targets.Performance-based financinghasbeen introduced inCameroonasa jointinterventionbytheministryofhealthandtheWorldBankGroup.AnimpactevaluationconductedinCameroonsuggestedthatPBFhadimpactonsomehealthsectorsandbutnotonothers.ReflectionsontheapproachhavesuggestedthatincreasingdemandmaybestrategicinmakingPBFevenmoreefficient.Thereareexistingopportunities includinguseof layhealthworkersthatcouldbeusedtomobilizecommunitiestosupporthospitalperformanceandincreasedemand.

Objectives:ToevaluatethefinancialcontributionofPBFtohealthfacilitiesinCameroon.Toevaluatethecontributionofcommunityinvolvementinimprovinghealthfacilityperformance.

Methods: Community monitoring was developed as an approach to facilitate communitymobilizationprocessforhealthcaredemand,supportinghealthfacilitiestobemoreperformantandadding value to the activities of community health workers. It utilized a community mobilizationapproach toprovide feedbackon communityhealthpriorities. This feedback considers communityissues, hospital performance and community health workers performance and incorporated intohospital’sbusinessplan. Theapproachwasused in fourhealthdistricts in theNorth-WestRegionbetween2015and2017and96communitiesexperiencedthisapproach.

WecalculatedthecontributionsofPBFtohospitalproduction(equityandqualitybonuses),qualityofcare,outreach,andabilitytousecommunityvoicefordecisionmaking.Wefocusedondiseaseswithhighestdiseaseburden,includingmalaria,HIV/AIDSandsexualandreproductivehealthservices.

A qualitative assessment is important because it helps with bringing out the experiences ofcommunities,health facilitiesandcommunityhealthworkers,whichwillhelp inmeaningfulnessoftheprogramtothesegroups.Experiencesandmeaningfulnesshavebeenshowntoplayakeyroleinglobalhealth,policyandpractice,andtheevidenceecosystem.

Results:Totalquarterlyproductionsincreasedforallindicatorsandacrossalldistrictsbyameanof3,722.8 score (R: 1,244 – 6,629) new services provided. Three out four districts showed meanimprovementsinqualityof3.5points(R:1.6-5.1)over15monthsperiodwhileonehealthdistrictshoweddepreciationinqualityby-12.3points,withdepreciationsbeinguniformacrossalltechnicalquarterlyqualityassessments.

Discussions:PBFhasbecometrendywithAfricanhealth systems. It ispopularamongsthealthcareworkers.However, there isneedto takerelevantevidencetopolicymakers includingcostanalysisandimpactonburdenofdisease.

Assessment of NHIS-MDG Free Maternal and Child Health Program in North Central Central Nigeria: Achievements and challenges

*UchennaEzenwaka,*ObinnaOnwujekweEmmanuel,**HyacinthIchokuEment:Healt1.*PolicyResearchGroup,**DepartmentofEconomics,UniversityofNigeria,Nsukka.

Background: TheNigerian government launched a pilot health project, titled the “NHIS-MDG freeMaternalandChildHealthProgram”in2018.Theprogramfocusestoaddressthecriticalproblemofaccesstohealthcareservicesforpregnantwomenandchildrenunderfiveyearsinthecountryand


to accelerate the achievement of two of the three health specificMDGs (4&5). The programwasimplemented in some states in Nigeria between 2009 and 2015 using funds from the debt reliefgains.ThefundsweredirectlydisbursedbytheMDGofficeinthepresidencytotheNHISforuseinprovidingtheservicestobeneficiariesintheimplementingstates.

AimandObjectives:Thisstudyassessedthe implementationexperiencesofthefreematernalandchildhealthcareprogram(FMCHP)withaviewtoidentifyingachievementsandchallengesfacedbytheprogramforreactivationandscale-upinNigerState,Nigeria.

Methods:ThestudyadoptedadescriptivequalitativedesigntoassesstheFMCHPatthestateleveland fourPHC in two Local governmentareas inNiger State.A total of 29 in-depth interviewswasconductedwith relevant respondents (policymakers,providers,HealthMaintenanceOrganizations)purposively selected to include those who were knowledgeable on the program and activelyparticipated in implementation.We also conducted focus-group discussions (n=4) with 27 serviceusers and facility ward development committee in communities where the program wasimplemented. A validation meeting was held with the respondents, to ensure accuracy ofinformation obtained. Datawere analyzed usingmanual thematic analysis derived from the studyconceptualframework.

Key Findings: The FMCHP was reported to have positive improvements and increased serviceutilization as a result of availability and accessibility of services offered. It also led to markedimprovement in the quality of health facilities.Most importantly, removal of financial barriers toaccessinghealthcarewithintheimplementationperiod.However,non-paymentoffullcounterpartfunds affected the program continuity. Other health system factors that negatively affected theprogramwereinadequatehumanresourcesresultingfromtheincreasedworkload,weakmonitoringandHealthInformationManagementSystem.

Conclusions:Theprogram’scentralachievementwasremovalofout-pocketpaymentwhichisoneofthemostsevereimpedimentstoaccessinghealthservices inNigeria.Financialsustainabilityshouldbe properly addressed if the program is to be reactivated, otherwise the country’s health caresystemwillremainunimprovedandwillnotassureUHCfortargetbeneficiaries.

Keywords:FMCHP;MDG;NHIS;NIGERIA

Assessing sub-national health system’s capacity to deliver primary care for diabetes mellitus and hypertension in Kenya

RobinsonOmondi,MartinNjoroge,KennethMunge:KEMRICentre forGeographicMedicineResearch,Coast,KiIifi,Kenya

Background: The growing burden of non-communicable diseases (NCDs) presents an emergingchallenge to Kenya’s health system ability to provide interventions and services. Kenya’s healthpolicyaims tohaltandreverse therisingburdenof thesediseasesandtostrengthenprimarycareservices.Subnational (county)governmentsarecrucial todeliveryofhealth services inKenya.Thisstudy critically appraised the subnational health system’s current capacity to deliver services fordiabetesandhypertensionatprimarycarelevel.

Methods:Weusedacross-sectionalqualitativeapproachwithprimarycare servicesat thecountygovernment level as the unit of analysis. We collected data through document reviews (policy,statutes and budgets), in-depth interviews with senior county officials (n=7) and with facilitymanagers and front-line health workers (n=15) in one county in Kenya. Facility audits of staffnumbers and mix, availability of medical equipment, and essential drugs, were conducted in 3hospital clinics and 3 primary care facilities to triangulate interview findings. Data were analyzedusingaframeworkapproach.


Results: Therewere gaps in hardware elements of capacity including financing, human resources,servicedeliveryandcommoditiesastherewereinadequatequantitiesoftheseresourcestoaddresstheuniqueneedsofdiabetesandhypertension.Sometangiblesoftwareelementsofcapacitysuchasorganizational arrangements were present e.g. an official responsible for these diseases; thoughotherssuchastreatmentguidelinesandadequatereferralarrangementswereabsent.Powerresidedwithpoliticalleadersandcontrollersoffinancewhoinfluencedtheresourcingandconsequentlythemanagementofthesediseases.Asaresult,facilitymanagersfeltunabletoaddresstheresourcegapsthat would have improved service delivery. Front-line workers felt the need for routine capacitybuildingtoofferthebestservicepossible.Comprehensivenessofcarewasaffectedbytheabsenceof equipment and the lackof staff diversity. Coordinationand continuityof carewereaffectedbypoor information systems, staffing gaps and gaps in quality of care. Accessibility was supportedthrough use of ambulances, increased investment in physical infrastructure and through waiversystems.

Conclusions:Countygovernmentsshouldprovideadequateresourcesrequiredtofillinthehardwarecapacity gaps especially at primary care level. Tangible software capacity gaps such as standardtreatment guidelines, training and supervision of front-line workers should also be urgentlyaddressedtocomplementexistingintangiblesoftwarecapacity.

Assessment of adolescents sexual behaviour as risk factor for HIV infection among in-school adolescents in Ondo State, Nigeria

AbdulazeezAdewale,UniversityofBenin

Background:HIV/AIDSinfectionamongstadolescentsinsub-SaharaAfricacountriesincludingNigeriahasattractedglobalattentionandseveralstudieshaveidentifiedsexualriskbehaviourasthemajorriskfactorenhancingthetransmissionofHIVinfection.

Rationale:TheincreasingcasesofHIVinfectionsamongstadolescentsareworrisome,andthethusneedtoassessadolescents’sexualbehaviourinordertoidentifythepatternandprevalenceofriskysexual behaviours (RSBs) that can put them at the risk of contracting HIV infection and makerecommendationstorelevantstakeholdersinaddressingidentifiedproblems.

Methodology:Adescriptivecross-sectionalstudydesignconductedinOndoStateNigeriatoassesssexualbehaviourasariskfactorforHIVinfectionamongin-schooladolescents.Multi-stagesamplingtechnique was used to select consented 400 in-school adolescents aged 15-19years and datacollectedwiththeaidofpretested,structured;self-administeredquestionnaire.Descriptivestatisticssuch as frequencies and percentage distribution were used to show the distribution of the studysampleaccordingtoselectedstudyvariables,statisticaltestingwasdoneusingChi-squareatthe0.05levelofsignificance.

Result: The study revealed that the major prevalent risky sexual behaviours among adolescentsinclude early sexual debut, premarital sex, unprotected sexual intercourse and multiple sexualpartner.Sexualactivityratewas28.7%,meanageofsexualdebut15.7+7years,38%ofwhichwasduetocoercion(rape).40.6%engagedinsexwithmultiplepartnersandtheprevalenceofunprotectedsex is 62.6%. Themajority (38%) uses condom prevent unwanted pregnancy rather than HIV andSTIs.

Male gender is significant determinant of adolescents sexual behaviour, others include advancingageandclassofrespondents,polygamousfamilysetupandsinglestatus.ThesedeterminantsneedtobemodifiedtoreducetheriskcontractingHIVinfection.

Respondentshavegood(59.0%)levelofknowledgeofHIVbasicfacts,preventionandcure,andgood(67.0%)levelofknowledgeofthemodeoftransmission,andhigh(73.5%)levelofbasicknowledgeof


sexualandreproductivehealth.ThereisasignificantassociationbetweenthelevelofawarenessofHIV/AIDSandprevalenceofriskysexualbehavioursamongstadolescentsat0.05levelofsignificant.

Conclusion:Highriskysexualbehaviours intheformofearlysexualdebut,premaritalsex,multiplesexual partners andunprotected sexual intercourse among the adolescents are risk of contractingHIV infection. All relevant stakeholders are recommended to promote specific interventionprogrammesthatwillenhanceadolescents’knowledgeofHIVandbehaviouralchangeinaddressingtheriskofHIVinfection.

Political Instability: a major concern for Prepayment Health Financing in Sub-Saharan African countries

YannTapsoba,OuagadougouCenterforstudiesandresearchesoninternationaldevelopment(CERDI)

Thepaperexamines the roleofpolitical instabilityonprepaymenthealth financing inSub-SaharanAfrica. Political instability reduces prepayment health expenditures. The effect passes by a taxrevenues reduction and the disrespect of rules of law. In addition the cooperation between SSAcountries and international community attenuates the adverse effect of political instability onprepayment health expenditures. The paper suggests taking actions to avoid political instabilityevents,tofindothersourcesofhealthfinancingexceptthetaxrevenues,mostlyinperiodofpoliticalinstability,andtopromotethecooperationwithinternationalcommunityandtherespectofrulesoflaw.

Economic Burden of Treatment for Child Undernutrition in Low and Middle-Income Countries: A Systematic Review

RebeccaGathoni1,*,JayBerkley1,2,JulieJemutai11KEMRIWellcomeTrustResearchProgramme,Kilifi,Kenya,2CentreforTropicalMedicineandGlobalHealth,NuffieldDepartmentofClinicalMedicine,UniversityofOxford,Background: Undernutrition is highly prevalent in low and middle-income countries with sub-Saharan Africa and Southern Asia accounting for majority of the cases. Apart from the humanimpactsincludingmortalityandmorbiditytoaffectedchildren,therearehugeeconomicimpactstohouseholds,societyandthegovernmentthatneedfurtherexploration.

Objectives:Themainaimofthisstudywastodeterminethecurrentstateofknowledgeonthecostsofchildundernutritiontreatment(s)tohouseholds,healthproviders,organizationsandgovernmentsinlowandmiddle-incomecountries(LMICs).

Methods: We conducted a systematic review using Preferred Reporting Items for SystematicreviewsandMeta-Analyses(PRISMA)guidelines.Literaturesearchwasdoneforarticlespublishedupto November 2017 for studies done in low and middle-income countries. Databases searchedincluded PubMed-Medline, Embase, Popline, Econlit andWeb of science. Additional articles wereidentifiedthroughbibliographiccitationsearchesandGooglescholar.Onlyarticlesincludingcostsofchildundernutritiontreatment(s)wereincluded.

Results:Theliteraturesearchyielded6177articles,amongthese,only44metourinclusioncriteria.The studies varied in the interventions studied, perspective(s) adopted and costingmethods usedwithsomestudiesreportingcostsaslowasUS$0.44perchildandashighasUS$1344costperchild.Themaincostdriversforhouseholdsandcommunityvolunteersweretheopportunitycostoftimespentawayfromnormaldutieswhileseekingtreatment.Personnelcostsandtherapeuticfoodwerethemain drivers of costs incurred by the government, health providers and organizations funding


interventionsaimedatmanagingundernutritioninchildren.Oneofthecopingstrategiesadoptedbythehouseholdswasemployingpeopletotakecareoftheirdutieswhileseekingtreatment.

Conclusion: There isneed toaddress theeconomicburdenof childundernutritiononhouseholds,health providers and the government through collaborative and sustained effort. Researchers andother development partners need to team up to identify locally appropriate evidence based andcost-effectiveinterventions.Further,thisreviewrecommendsastandardizationofthemethodsusedand results reported in economicevaluations to facilitatemeaningful interpretationandprovide ausefulmeansforcomparingcostsandcost-effectivenessofinterventions.

Extent, distribution and correlates of household catastrophic expenditure for health in Kaduna state, Nigeria

ChukwuemekaAzubuike,YewandeOgundeji,KelechiOhiri:AbujaHealthStrategyandDeliveryFoundation

Background: InNigeria, householdout-of-pocketexpenditure (OOP)hasbeen themajor sourceofhealth financing, constituting about 73%of total health expenditure. This ismainly due to lack offinancial protection, which is a predominate barrier of access to health services. High OOP oftenresultsincatastrophichealthspending(>5%-40%oftotalhouseholdexpenditureonhealth),whichleadstoimpoverishmentespeciallyforthepoorandvulnerable.AsNigeriamovestowardsachievinguniversalhealthcoveragebydesigningeffectivepro-poorfinancialprotectionschemes,evidenceontheextentofOOPexpendituresonhealthandcatastrophicincidenceonhouseholdsarerequiredfordecision making. This study examined health expenditure among households in Kaduna state, toestimatetheextentanddistributionofcatastrophicexpenditureonhealth.

Methods:Weutilizeddata fromtheKadunastate2017householdhealthexpendituresurvey.Thissurvey reported socioeconomic, general expenditure, healthcare expenditure, and healthcareutilization data across a representative sample of 1020 households. The proportion of healthexpenditurerelativetoincomewasderivedasfollows:R=Hexp/HHInc*100.WhereRistheshareof health expenditure in income, Hexp is the average monthly spending on health, HHinc is theaveragemonthly household income.We also explored association between catastrophic spendingandsocioeconomicfactorsusingregressionmodels.

Results:Thetotalannualper-capitaOOPwas19,795Naira($64.9),whichtranslatestocatastrophicspendingin57%ofsampledhouseholdsandusingathresholdof≥10%ofhouseholdincome,whilstcatastrophicspendingwasexperiencedby36%ofsampledhouseholdsusingathresholdof≥40%ofhousehold income. In addition, 67.2% of the poor households experienced catastrophic healthspending, compared to41.5%among the richesthouseholds.Householdswerealsomore likely toincurcatastrophicexpendituresiftheheadofhouseholdwasfemale.

Conclusion: At 19,795Naira ($64.9), KadunaOOP is relatively higher than the national average of15,037 Naira ($49.3), which is the highest in Africa. It is evident that this burden is bornedisproportionatelybythepoorandthoseintheruralareas.Inthecontextofanabsenceoffinancialriskprotectionmechanisms,aviciouscycleofpoverty, ill-healthandpooroutcomesisperpetuatedespeciallyamongthepoor.Thepoor inKadunastatearewellpositionedtobenefitfromthesocialcontributory scheme and other financial protection mechanisms being planned by the state toreduceoutofpocketexpenditureforthepoorandvulnerable.

Equity and Universal Coverage: A Trend Analysis of WHO Target Indicators in then Context of Nigerian Health System

*ChristopherKalu,**Dr.CharlesC.Ezenduka:*AfricanDept.ofHealthAdm&Mgt,UNEC,Nigeria,**Dept.ofHealthAdm&Mgt,UNEC,Nigeria


Background: Improving and enhancing the performance or the overall functioning of the healthsystemandachievingequitableaccessandaffordabilityofhealthcareservicestoallisamajorefforttowardsuniversalcoverage.TheWorldHealthOrganization(WHO)proposedfourtarget indicatorsfor countries including Nigeria to use to measure progress towards achieving universal coverage(UC).Theyare:1)Totalhealthexpenditureshouldbeatleast4%-5%ofthegrossdomesticproduct(GDP).2)Out-of-pocketexpenditureshouldnotexceed30-40%oftotalhealthexpenditure.3)Over90% of the population is covered by pre-payment and risk pooling schemes; 4) close to 100%coverageofpopulationwithsocialassistanceandsafetyprogrammes

Objective/Aim:Theoverallobjectiveofthepaperistoexaminetherelationshipbetweenequityandtheattainmentofuniversalcoverage.Specifically,itaimsatanalyzingtheNigerianhealthsysteminrelationtoWHOtargetindicatorsforUC.

Methodology:Thepaperadoptedthedescriptive/trendanalysisapproach.Thisapproachissuitabletothestudymainlybecauseof its relevancetoachievingtheobjectivesof thestudy.Thescopeofthestudyisfrom2010-2018andthedatausedintheanalysisweresourcedfromtheNigerianhealthsystemrecords,documentsandWorldBankDevelopmentIndicator,(WDI,2017).

KeyFindings:Thefindingsfromtheanalysisrevealedthatout-of-pocketexpenditureforhealthandpoorservicedeliveryareamongthemajorcontributorstothehealthinequityintheNigerianhealthsystem.Moreover,theanalysisshowedthattheNigerianhealthsystemindicatorsisnotinlinewiththeWHO recommendations, resulting to low level of access to healthcare, rising health poverty,inequity,andlowlevelofcoverageamongothers.

Conclusion:ThispaperusingWHOparametersforUChasonceagainshowntheincidenceofhealthinequities in the Nigerian health system. Inequities in access and use of healthcare services andcopingwithpaymentsontreatmentprovidegreatobstaclestoachievingUCinNigeriaandnodoubtleadstolowlevelsoffinancialriskprotection,decreaseaffordabilityofserviceandgenerallowlevelsof coverage with health services. There is need for Nigerian health system managers andadministrators to draw lessons from countries (Ghana inclusive) that have achieved universalcoverage.

KeyWords:Equity,efficiency,universalcoverage,WHOtargetindicators,Nigeria.

Health expenditure at the sub-national level in Nigeria: Evidence from the Kaduna State Health Accounts 2016

YewandeOgundejiAbuja,EmekaAzubike,KelechiOhiri:HealthStrategyandDeliveryFoundation

Background: The health accounts provide accurate estimates of health expenditure, which areimportantforeffectiveresourceallocationandplanninginthehealthsector.InNigeria,tworoundsofhealthaccountshavebeenconductedatthenationallevel.However,thesenationalestimatesdonot necessarily reflect estimates at the subnational level, and hence cannot be reliably used fordecisionmaking and/or planning at those levels. This study presents the process of conducting asubnationalhealthaccountsanditsresultsinKadunaState,Nigeria.

Methods:Weutilizeddata fromprimary and secondary surveys.Healthexpenditure surveyswereadministered to relevant organizations in the health sector for the reference year of 2016.Householdhealthexpenditurewasderivedfromahouseholdsurveyacrossarepresentativesampleof households in the state. Secondary data were obtained from government audited reports andfinancial statements. We also utilized the health management information system (DHIS2) andconducted a health provider survey across a representative sample of health facilities to estimate


diseaseexpenditure.AnalyseswereconductedusingMicrosoftExcel,STATAandtheHealthaccountproductiontool(HAPT).

Results:TheaggregatehealthexpenditurewasestimatedatN183billion($600million),representing7%ofthestate’sGDP;99%ofwhichwasoncurrentexpenditure(N181billion).Governmentcurrenthealthexpenditure (CHE)accountedforonly7%of totalCHE,andonly25%of thisproportionwasspent on primary care. Households spent about 81% of CHE, compared to a national average of71.5%ofCHEandtherecommendedbenchmarkof30%ofCHE.

Discussionandconclusion:TheKadunastatehealthfinancingsystemisheavilydependentonoutofpocket financing(81%ofCHE),whichtranslatestocatastrophicspendingespecially forthepoor.Ashift towards a well designed and implemented pooled prepayment mechanisms such as acontributory health insurance schemewould promote risk equalization and cross subsidization toreduce financial burden on the poor. In addition, given the governments meagre contribution tohealth expenditure (10%), there is a strong need to improve government prioritization andexpenditureonhealthespeciallyforprimarycare.

Effect of National Health Insurance Authority’s medecine reimbursment prices on the occurrence and affordability of medecine co-payment practice among national health insurance acredited providers

GyasiDPandAgyei-BaffourP,NationalHealthInsuranceSecretariat,GhanaHealthServiceHeadquarters,AccraPeter Agyei-Baffour (PhD), Department of Community Health, School ofMedical Sciences, College of HealthSciences,KwameNkrumahUniversityofScienceandTechnology,Kumasi,Ghana;

In most developing countries, access to basic essential medicines needed to save lives may beimpededduetothemenaceofpovertythatplaceslargerproportionofthepopulationfromfinancialaccesstohealthcare.Fortunately,GhanaintroducedNationalHealthInsurancein2004asmeansoffinancing healthcare, efforts at achieving universal health coverage and addressing gaps in healthoutcomes. However, infrequent reviews of the medicines reimbursement prices to contain thefluctuating economic trends makes National Health Insurance Authority’s (NHIA) reimbursementpricesbecomeobsoleteasquicklyastheyareset.Thisstudyevaluatestheeconomicimplicationsofinfrequent reviews of reimbursement prices for tracer essential medicine on the occurrence andaffordability of co-paid cost of medicines among accredited health facilities in Ejisu-JuabenMunicipality.Across-sectionalstudyinvolvingreviewofinventoryrecordsandinvoicesofpurchasesof thirty four tracermedicines allowable at all levels of healthcarewas done retrospectively fromMarch2016-December2016.Amulti-stageclustersamplingwasdeployedtoinitiallyformclustersofhealth facilities based on ownership types of public, private, mission facilities respectively.Consequently,fifteenfacilitieswereselectedthroughsimplerandomsamplingfromasub-clusteroffacilitiesformedwithinthemainclustersbasedonlevelofcareofthefacilities.Quantitativemethodwas used to assess micro-economic indicators of affordability based on daily minimum wage ofclients, indirectand intangiblecostonmedicines.Providers’perceptionsonaffordabilityofco-paidcostofmedicineswerealsosoughtthroughkeyinformantinterview.DatawasanalysedusingStatasoftware version 12 andMicrosoft Excel Version 2013. Sensitivity analysiswas done to assess therobustnessoftheestimatesovertime.Thestudyestablishedmedicineco-paymentinmajority(7in10)toptenOPDconditionsinprivatelyowned,few(4in10)toptenOPDconditionsinmissionandpublichealth facilitiesaccreditedbyNHIA.However, theamounts co-paidaregenerally affordable(FDW≤1).Frequentreviewsorindexationofreimbursementmaybehelpful.

Keywords:Insurance,Reimbursement,Health,Pharmacy,Tariff,Price,Medicine

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