Protecting the poor under cost recovery: the role of means testing.
(9/2725)
In African health sectors, the importance of protecting the very poor has been underscored by increased reliance on user fees to help finance services. This paper presents a conceptual framework for understanding the role means testing can play in promoting equity under health care cost recovery. Means testing is placed in the broader context of targeting and contrasted with other mechanisms. Criteria for evaluating outcomes are established and used to analyze previous means testing experience in Africa. A survey of experience finds a general pattern of informal, low-accuracy, low-cost means testing in Africa. Detailed household data from a recent cost recovery experiment in Niger, West Africa, provides an unusual opportunity to observe outcomes of a characteristically informal means testing system. Findings from Niger suggest that achieving both the revenue raising and equity potential of cost recovery in sub-Saharan Africa will require finding ways to improve informal means testing processes. (+info)
The role of private providers in maternal and child health and family planning services in developing countries.
(10/2725)
This paper uses data from the Demographic and Health Surveys program (DHS) in 11 countries in Asia, Africa, and Latin America to explore the contribution of private health care providers to population coverage with a variety of maternal and child health and family planning services. The choice of countries and services assessed was mainly determined by the availability of data in the different surveys. Private providers contribute significantly to family planning services and treatment of children's infectious diseases in a number of the countries studied. This is as expected from the predictions of economic theory, since these goods are less subject to market failures. For the more 'public goods' type services, such as immunization and ante-natal care, their role is much more circumscribed. Two groups of countries were identified: those with a higher private provision role across many different types of services and those where private provision was limited to only one or two types of the services studied. The analysis identified the lack of consistent or systematic definitions of private providers across countries as well as the absence of data on many key services in most of the DHS surveys. Given the significance of private provision of public health goods in many countries, the authors propose much more systematic efforts to measure these variables in the future. This could be included in future DHS surveys without too much difficulty. (+info)
Ability to pay for health care: concepts and evidence.
(11/2725)
In many developing countries people are expected to contribute to the cost of health care from their own pockets. As a result, people's ability to pay (ATP) for health care, or the affordability of health care, has become a critical policy issue in developing countries, and a particularly urgent issue where households face combined user fee burdens from various essential service sectors such as health, education and water. Research and policy debates have focused on willingness to pay (WTP) for essential services, and have tended to assume that WTP is synonymous with ATP. This paper questions this assumption, and suggests that WTP may not reflect ATP. Households may persist in paying for care, but to mobilize resources they may sacrifice other basic needs such as food and education, with serious consequences for the household or individuals within it. The opportunity costs of payment make the payment 'unaffordable' because other basic needs are sacrificed. An approach to ATP founded on basic needs and the opportunity costs of payment strategies (including non-utilization) is therefore proposed. From the few studies available, common household responses to payment difficulties are identified, ranging from borrowing to more serious 'distress sales' of productive assets (e.g. land), delays to treatment and, ultimately, abandonment of treatment. Although these strategies may have a devastating impact on livelihoods and health, few studies have investigated them in any detail. In-depth longitudinal household studies are proposed to develop understanding of ATP and to inform policy initiative which might contribute to more affordable health care. (+info)
Reducing perinatal mortality in developing countries.
(12/2725)
The perinatal mortality rate (PNMR) is a key health status indicator. It is multifactorial in aetiology and is significantly influenced by the quality of health care. While there is an ethical imperative to act to improve quality of care when deficiencies are apparent, the lack of controls--when an interventions is applied to an entire service--makes it difficult to infer a causal relationship between the intervention and any subsequent change in PNMR. However, by specifically measuring avoidable perinatal deaths (those due to error or omission on the part of the health service), this limitation is partially overcome, and the impact of the intervention can be more rigorously evaluated. This paper reports the impact of perinatal audit in a rural African health district between 1991 and 1995. A total of 21,112 consecutive births were studied: the average number of deliveries increased by 31% from 325 to 424 per month. The PNMR (birth weight > or = 1000g) in 1991 was 27/1000, increased to 42/1000 in 1992, and fell steadily to 26/1000 in 1995 (40% reduction; p = 0.002). The proportion of avoidable deaths fell from 19% in 1991 to zero in the second half of 1995 (p = 0.0008). While factors associated with perinatal mortality are many, complex, and interrelated, this report suggests that mortality can be reduced significantly in resource-poor settings by improving quality of health care. Including the measurement of avoidable deaths in perinatal audit allows the impact of interventions to be more rigorously assessed than by simple measuring the PNMR. (+info)
The lessons of user fee experience in Africa.
(13/2725)
This paper reviews the experience of implementing user fees in Africa. It describes the two main approaches to implementing user fees that have been applied in African countries, the standard and the Bamako Initiative models, and their common objectives. It summarizes the evidence concerning the impact of fees on equity, efficiency and system sustainability (as opposed to financial sustainability), and the key bottlenecks to their effective implementation. On the basis of this evidence it then draws out three main sets of lessons, focusing on: where and when to implement fees; how to enhance the impact of fees on their objectives; and how to strengthen the process of implementation. If introduced by themselves, fees are unlikely to achieve equity, efficiency or sustainability objectives. They should, therefore, be seen as only one element in a broader health care financing package that should include some form of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with fees. There is a greater potential role for fees within hospitals rather than primary facilities. Achievement of equity, efficiency and, in particular, sustainability will also require the implementation of complementary interventions to develop the skills, systems and mechanisms of accountability critical to ensure effective implementation. Finally, the process of policy development and implementation is itself an important influence over effective implementation. (+info)
How and why public sector doctors engage in private practice in Portuguese-speaking African countries.
(14/2725)
OBJECTIVE: To explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public service. DESIGN: Cross-sectional qualitative survey. SUBJECTS: In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozambique and three from S Tome and Principe answered a self-administered questionnaire. RESULTS: All doctors, except one unemployed, were government employees. Forty-three of the 68 doctors that answered the questionnaire reported an income-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public sector medical care, private medical care, commercial activities, agricultural activities and university teaching. The two outstanding reasons why they engage in their various side-activities are 'to meet the cost of living' and 'to support the extended family'. Public sector salaries are supplemented by private practice. Interviewees estimated the time a family could survive on their public sector salary at seven days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become marginal for those in the urban areas (median 10%). For the latter, private practice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generated by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The social contacts and public service gave access to power centres and resources, through which other coping strategies could be developed. The expectations regarding the professional future and regarding the health systems future were related mostly to health personnel issues. CONCLUSION: The variable response rate per question reflects some resistance to discuss some of the issues, particularly those related to income. Nevertheless, these studies may provide an indication of what is happening in professional medical circles in response to the inability of the public sector to sustain a credible system of health care delivery. There can be no doubt that for these doctors the notion of a doctor as a full-time civil-servant is a thing of the past. Switching between public and private is now a fact of life. (+info)
The robust australopithecine face: a morphogenetic perspective.
(15/2725)
The robust australopithecines were a side branch of human evolution. They share a number of unique craniodental features that suggest their monophyletic origin. However, virtually all of these traits appear to reflect a singular pattern of nasomaxillary modeling derived from their unusual dental proportions. Therefore, recent cladistic analyses have not resolved the phylogenetic history of these early hominids. Efforts to increase cladistic resolution by defining traits at greater levels of anatomical detail have instead introduced substantial phyletic error. (+info)
Dose-dependent inverse relationship between alcohol consumption and serum Lp(a) levels in black African males.
(16/2725)
Serum or plasma levels of Lp(a) vary widely between individuals and are higher in Africans and their descendants compared with white persons. In whites, high serum levels of Lp(a) are associated with the premature development of atherosclerosis. In both ethnic groups, serum Lp(a) levels are highly genetically determined and only a few environmental or physiological factors, like testosterone or estrogen, have been shown to lower serum Lp(a) levels. In whites, alcohol consumption is associated with lower serum Lp(a) levels. However, the mechanism underlying this association and whether it holds true for blacks is not known. To address these questions, we analyzed serum Lp(a) levels in 333 middle-aged males of African descent from the Seychelles Islands (Indian Ocean). In addition, we analyzed the size of the apo(a) isoforms and the serum levels of albumin and sex hormones in a subset of 279 subjects. Serum Lp(a) levels were similar in teetotalers (median, 32.5 mg/dL; n=42) and occasional drinkers (median, 34.1 mg/dL; n=112). In contrast, individuals consuming 10 to 80 g of ethanol/d (n=83) and heavy drinkers (>80 g of ethanol/d, n=96) had a 9% and 32% lower median Lp(a) level than teetotalers, respectively (P=0.01). The size distribution of the apo(a) isoforms and the mean serum levels of albumin, estradiol, and luteinizing hormone were similar in teetotalers and occasional drinkers compared with moderate and heavy drinkers. These latter 2 groups had lower serum levels of testosterone and sex hormone-binding globulin. These data indicate that alcohol intake is associated in a dose-dependent manner with lower serum Lp(a) levels in males of African descent and that this association is not related to the size of the apo(a) isoforms, to the synthetic function of the liver, or to sex hormone biochemical status. (+info)