Donor funding for health reform in Africa: is non-project assistance the right prescription?
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During the past 10 years, donors have recognized the need for major reforms to achieve sustainable development. Using non-project assistance they have attempted to leverage reforms by offering financing conditioned on the enactment of reform. The experience of USAID's health reform programmes in Niger and Nigeria suggest these programmes have proved more difficult to implement than expected. When a country has in place a high level of fiscal accountability and high institutional capacity, programmes of conditioned non-project assistance may be more effective in achieving reforms than traditional project assistance. However, when these elements are lacking, as they were in Niger, non-project assistance offers nothing inherently superior than traditional project assistance. Non-project assistance may be most effective for assisting the implementation of policy reforms adopted by the host government. (+info)
The impact of alternative cost recovery schemes on access and equity in Niger.
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The authors examine accessibility and the sustainability of quality health care in a rural setting under two alternative cost recovery methods, a fee-for-service method and a type of social financing (risk-sharing) strategy based on an annual tax+fee-for-service. Both methods were accompanied by similar interventions aimed at improving the quality of primary health services. Based on pilot tests of cost recovery in the non-hospital sector in Niger, the article presents results from baseline and final survey data, as well as from facility utilization, cost, and revenue data collected in two test districts and a control district. Cost recovery accompanied by quality improvements increases equity and access to health care and the type of cost recovery method used can make a difference. In Niger, higher access for women, children, and the poor resulted from the tax+fee method, than from the pure fee-for-service method. Moreover, revenue generation per capita under the tax+fee method was two times higher than under the fee-for-service method, suggesting that the prospects of sustainability were better under the social financing strategy. However, sustainability under cost recovery and improved quality depends as much on policy measures aimed at cost containment, particularly for drugs, as on specific cost recovery methods. (+info)
Protecting the poor under cost recovery: the role of means testing.
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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)
Improving quality through cost recovery in Niger.
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New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements. (+info)
Increasing the utilization of cost-effective health services through changes in demand.
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Attaining efficiency in a health care system with a budget constraint involves increasing the utilization of the most cost-effective services. This can be achieved by adjustments to prices, cost curves, or demand curves. In this paper, the potential for demand curve adjustments is examined by selecting two apparently cost-effective services (prenatal care and childhood immunization against tuberculosis), and analyzing the factors explaining their utilization. Data from recent household surveys in Burkina Faso and Niger are used. A multivariate analysis of utilization employs income, price, and taste variables. Utilization is highly sensitive to the distance which must be travelled to the health facility, a price, and taste variables. Utilization is highly sensitive to the distance which must be travelled to the health facility, a price variable. Members of certain ethnic groups tend to use the services less, other things being equal. The importance of demand-side factors like ethnicity points to certain kinds of policy interventions like information, education and communication activities which could increase the utilization of cost-effective services. (+info)
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esearch note: does cost recovery for curative care affect preventive care utilization?
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User fees and patient behaviour: evidence from Niamey National Hospital.
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Evidence is presented on the effects of price changes on the delay before seeking care and on referral status in a sample of hospital patients in Niger. Price changes are measured as differences across patients at one hospital in whether or not they pay for care, rather than as differences in prices across several hospitals. User fees are charged, but the fee system allows exemptions for some payor categories such as government employees, students, and indigent patients. Evidence is also presented on the effect of income on the delay before seeking care and referral status. The analysis demonstrates a technical point on whether household consumption or current income is a more appropriate measure of income. The analysis shows that user fees affect patient behaviour, but the effects are not the same for outpatients and inpatients. Outpatients who pay for care wait longer before seeking care, but inpatients do not. Inpatients who pay for care are more likely to be referred, but outpatients are not. Patients with more income wait less time to seek care and are less likely to be referred than other patients. Further, household consumption explains patient behaviour better than current income. (+info)
Epidemiology of bacterial meningitis in Niamey, Niger, 1981-96.
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In the African meningitis belt the importance of endemic meningitis is not as well recognized as that of epidemics of meningococcal meningitis that occur from time to time. Using retrospective surveillance, we identified a total of 7078 cases of laboratory-diagnosed bacterial meningitis in Niamey, Niger, from 1981 to 1996. The majority (57.7%) were caused by Neisseria meningitidis, followed by Streptococcus pneumoniae (13.2%) and Haemophilus influenzae b (Hib) (9.5%). The mean annual incidence of bacterial meningitis was 101 per 100,000 population (70 per 100,000 during 11 non-epidemic years) and the average annual mortality rate was 17 deaths per 100,000. Over a 7-year period (including one major epidemic year) for which data were available, S. pneumoniae and Hib together caused more meningitis deaths than N. meningitidis. Meningitis cases were more common among males and occurred mostly during the dry season. Serogroup A caused 85.6% of meningococcal meningitis cases during the period investigated; three-quarters of these occurred among children aged < 15 years, and over 40% among under-5-year-olds. Both incidence and mortality rates were highest among infants aged < 1 year. In this age group, Hib was the leading cause of bacterial meningitis, followed by S. pneumoniae. The predominant cause of meningitis in persons aged 1-40 years was N. meningitidis. Use of the available vaccines against meningitis due to N. meningitidis, S. pneumoniae, and Hib could prevent substantial endemic illness and deaths in sub-Saharan Africa, and potentially prevent recurrent meningococcal epidemics. (+info)