Bibliography: leaves 121-130. / Zimbabwe like many other countries in Sub-Saharan Africa is being ravaged by the effects of HIV/AIDS. Prevalence levels currently stand at between 15-35% (for women aged between 25-29), and are expected to grow to 50% by the year 2010. The economy is suffering from the loss of productive labour, the health sector is over-burdened and unable to cope with the increased demand for health services due to ADS related illnesses. Many households have lost their principal breadwinners to the disease and have become impoverished as a result. Despite a myriad of interventions aimed at preventing the spread of the infection, and mitigating its effects on the health system, the economy, and households, the infection still presents a problem for the country. Poor urban households in particular, are susceptible to poverty induced by the effects of this illness. It is therefore important to not only assess the costs of the disease on these households, but also to understand the strategies which .they employ to cope with the impact of the illness. The main aim of this study was to assess the costs (direct and indirect) incurred by poor households as a result of HIV /AIDS, and to explore the strategies which they make use of in dealing with the effects of the disease. Social capital was examined as a resource which households utilize in order to mitigate the impact of HIV/AIDS related ill health on the household. Data was collected from interviews of people living with HIV/AIDS (using a structured questionnaire), focus group discussions and key informant interviews. The sample of 110 people living with HIV/AIDS was drawn from two poor urban communities with different wealth profiles. The questionnaire was structured in order to obtain information on the costs incurred by households as a result of the disease and about the strategies employed to cope with the disease. The results indicate that HIV/AIDS places a heavy economic burden on affected households, many of whom already struggle to meet their basic needs. The results show that that most households (72%) enter into debt, and few make use of household savings and Medical Insurance as mechanisms for coping with the high costs of ill health. Both communities exhibited high levels of certain types of social capital resources, with the lower income community exhibiting higher levels of social capital resources in general. A pattern in the results reveals that the resources and forms of assistance (financial and non-financial) that households in the two communities had available to them for coping with the disease differed according to the type of social capital held by the respondents in the each community. An analysis of these results suggests that introducing structures to assist affected households in meeting their basic needs such as food and education would improve the ability of households to cope with the economic impact of the disease. The institution of means tested exemption systems for health care services for these people would greatly improve the ability of their households to cope with the high illness costs. The results also suggest that organisations and actors involved in HIV/AIDS interventions should co- ordinate their efforts so as to be effective in mitigating the effects of the disease on these households. It is also suggested that policy makers develop capacity in the area of social capital and HIV/AIDS so that interventions targeted at assisting communities affected by AIDS are informed by an understanding of the complete resource set (including differing social capital endowments) that households have at their disposal.

Bibliography: leaves 107-112. / This study examined the current resource allocation decision-making processes, and the distribution of both financial and non-financial resources in the health sector. The study explored how the current resource allocation process has impacted on equity between provinces (equity being defined as equal resources for equal need). It went further to look at possible alternatives that could lead the Kenyan health sector towards geographical equity. The study focused on the public health sector because it is the largest provider of health care services in Kenya. The basic argument underlying the study was that, raising additional funds for health care (e.g. through user fees) might not lead to equity, if the additional resources were to be allocated within the current resource allocation process. Instead, the study argues that the first step towards equity in health care in Kenya is to distribute the current resources in a more equitable manner. This can only be done through the development and implementation of a better resource allocation process.

Bibliography: leaves 71-74. / This paper studies the factors influencing the demand for ante-natal care in two of Nairobi's slum areas, namely, Kibera and Mathare. Antenatal care is important as its absence I underprovision means higher incidences of both maternal and infant mortalities. On the other hand proper ante-natal care means improved well-being of both mother and child. These two groups constitute over 70% of Kenya's population. For any economic and social development programmes to succeed, there is need to give mother and child special attention. The factors influencing the demand for ante-natal care could be grouped into three major categories; socio-economic (age, marital status, income etc.), facility (quality of care) as well as policy (user-fee) variables. The data for the analysis was obtained by means of a household survey conducted in Kibera and Mathare. A two stage sampling procedure was used for the data collection. This involved first, listing of all clusters from which a random selection of clusters to be studied was done and secondly, the households were drawn by a random sample within each of the selected clusters.

Includes bibliographical references (leaves 118-127). / In the face of rising morbidity and mortality due to HIV / AIDS epidemic in Sub-Saharan Africa, there has been an increasing pressure to provide life sustaining antiretroviral (ARV) drugs to countries in most urgent need of them. Antiretroviral Therapy (ART) has been identified by policy-makers in Uganda as a potential programme aimed at mitigating the pervasive effect of HIV / AIDS on the social and economic life of the country. Since 2000, the country has shifted its focus from primarily HIV prevention to paying equal attention to care and treatment including ART. Provision of the ART programmes have been made possible through concerted efforts of international and national organizations such as the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), the World Bank, Multi-country AIDS Programme (MAP), Great Lakes Initiative on AIDS (GLIA), the USA President's Emergency Plan for AIDS Relief (PEPFAR), UN agencies, Bi-lateral and Government of Uganda inputs (UAC 2004). New and increased funding notwithstanding, the Ugandan population has continued to grow exponentially at a rate of 3.5% and even though the economy has been growing at a rate of 6 % per annum, there is a widening disparity in incomes attributed largely to high levels of unemployment in the country (Ministry of Finance 2002). These income disparities have also greatly contributed to health inequities in Uganda, thus affecting the equitable allocation of the limited health resources including ART. The main aim of the study was to establish the socioeconomic status of those individuals who benefit most from the provision of free ARV drugs and to explore factors that influence the distribution of such benefits. The study was carried out in Kampala district (Uganda's capital city) and Masaka district. The study employed both qualitative and quantitative methods. Facility-exit interviews with patients accessing free ARVs formed the quantitative method, while Focus Group discussions with community representatives and in-depth interviews with key informants formed the qualitative part of the study. Quantitative data was obtained by use of a questionnaire, which was structured to obtain information on socioeconomic characteristics, including asset possession as a measure of wealth. A principal component analysis was run for both the Uganda Demographic Health Survey (UDHS) and facility-exit asset data to determine utilization of ARV by wealth quintiles. A benefit incidence costing model was also employed to determine monetary benefit of free ARVs in Uganda.

Sexually transmitted infections (STIs) remain a global public health concern. Together with bacterial vaginosis (BV), the association with HIV acquisition through genital inflammation in women poses a challenge towards the control of HIV/AIDS, more so in asymptomatic cases. Diagnosis of asymptomatic women using a genital inflammation screening tool, the cytokine biomarker rapid test, reduces the cases of untreated women. However, as a newly developed screening tool, there are no prior cost estimates to advocate for its funding and implementation. This study estimated the costs of genital inflammation screening of women (15-49 years) and, assessed the budget impact of providing this screening service in primary health facilities in South Africa in 2016. This thesis is a sub-study of the GIFT project (Genital Inflammation Test for HIV Prevention) whose main objective is HIV prevention through improved control of sexually transmitted infections (STIs). The micro-costing approach was used to calculate the unit cost per patient screened from a provider’s perspective at the Desmond Tutu HIV Foundation youth clinic (DTHF), and, the University of Cape Town Student Wellness Service (UCT SWS), over a 1 year period. The unit cost estimates were used to analyse the budget impact of scaling-up and providing the screening service in primary health facilities countrywide. . Sensitivity analyses were carried out to determine the robustness of the study findings. The results demonstrated that the cost per woman screened for genital inflammation was $24.26 at DTHF and $14.32 at UCT SWS. The scaled up costs ranged from $107,183,655 to $183,062,066 in South Africa. The screening intervention accounted for a significant amount of the available funds. The cost estimates were sensitive to the personnel costs, clinic utilization rates and population coverage rates. According to this study, it can be concluded that, the cost estimates of screening are high, and its implementation may not be affordable within the current budget. However, this screening tool will increase the cases detected, contributing towards better STIs management and control. Additionally, it will reduce the risk of HIV acquisition among women.

Bibliography: leaves 103-111. / Insecticide treated nets (ITNs) are a highly cost-effective tool in malaria control and has been associated with reductions in morbidity and mortality in children. Even though their efficacy has been established, the success of their use as a malaria control tool depends on their effective implementation and sustainability. The purpose of this study was to assess factors that would impact on household willingness and ability to pay for insecticide treated nets in the Bolgatanga district of Northern Ghana to provide insights into the sustainability of this tool. The paper presents the results of a survey of 876 household heads from both the rural and urban areas of the district. The survey questionnaire was designed to obtain information on perceived causes of malaria, health seeking behaviour, use of mosquito control products, consumption expenditure, income, possession of assets and demographic characteristics of the sample population. The contingent valuation method was used to elicit households stated willingness to pay for ITNS. The survey data was complemented by focus group discussions. Expressed willingness to pay for ITNs was as high as 92% but current usage of untreated bed nets among respondents was only 17%. The main reasons cited for low usage of nets were lack of ready cash, cost of nets and non availability. Mean maximum willingness to pay was 9120.00 cedis (US$3.8) which is lower than the current factory price of 13200.00 cedis (US$5.5). Willingness to pay was strongly determined by household size, the type of payment mechanism available, the use of untreated nets and possession of radio. Households are also more concerned about acquiring nets for the whole family rather than for the protection of the child. The lack of ready cash coupled with the percentage of income that poor households will require to buy insecticide treated nets will be an obstacle to net use. Poor households will require about 4.5% of total annual expenditure to be able to acquire an average of three nets adequate for the family at the expressed mean willingness to pay. At the present factory price they will need 6.6% to be able to buy three nets on average for family use compared to 1.5% from higher income earners. Inability to purchase nets for cash was also shown by the number of households willing to pay on an instalment basis. About 56% of households were willing to pay on credit basis against 18% that wanted to pay cash. Maximum willingness to pay was also higher among households willing to pay on a credit basis than for households willing to pay cash. Research into the feasibility of different payment schemes in local communities is very critical if this tool for malaria control is to be expanded and sustained. The feasibility of different financing mechanisms would not only reduce the initial cost of buying insecticide treated nets to households but would also increase willingness to pay and make payments for re-impregnation much easier. Research into how to protect the very poor and vulnerable should also be a focus in the promotion and use of ITNs.

Tuberculosis (TB) is the leading natural cause of mortality in South Africa, and the country has the sixth-highest TB burden in the world. Of every 100 000 South Africans, 781 are expected to develop TB. Even with the adoption of the Directly Observed Treatment, Short-Course (DOTS) strategy since 1996 and substantial investments and improvement in TB control, South Africa has failed to meet the TB-related targets set by the World Health Organization (WHO). The current burden of TB will lead to massive consequences of mortality and morbidity in the country besides the substantial financial implications for the health system. Considering the infectious nature of TB as a communicable disease, for the sake of controlling the level and spread of the disease as well as preventing drug resistance, adherence to treatment is essential. Moreover, the burden of non-adherence to TB treatment has been affirmed as one of the primary challenges facing global control of TB pandemic. The accessibility of needed care influences the adherence to treatment and in a situation in which non-adherence is the consequence of unjust and avoidable forces, the equity issue inflates its importance. Both barriers and facilitating factors to access and adherence to TB treatment are affected by different social determinants of health, inclusive of gender. Generally, the gender aspects of access to TB services have been an overlooked research area, and insufficient attention has been given to this aspect of TB control; although a number of previous studies, which had attempted to examine the association between gender and access barriers to TB treatment in different contexts, reported gender as a crucial factor in access to TB services. Hence, this dissertation aimed to explore the gender-based inequalities in access and adherence to TB services in South Africa, from the perspective of TB patients. This study relies on data drawn from the Researching Equity in Access to Health Care (REACH) project. Applying a comprehensive framework of access, interviews were conducted with 1229 TB patients from four health sub-districts in South Africa, to assess gender-related inequalities across the access dimensions of affordability, acceptability and availability of TB services. Descriptive statistics were computed, and comparisons of access barriers and adherence between men and women were explored using multivariate linear and logistic regressions. Based on the results, there was no significant association between levels of adherence and gender (all p-values> 0.05). Among availability-related variables, men spent significantly less time at the clinic to fetch TB medication (coefficient, -7.06; 95% CI, [-13.5, -0.7]); however with regards to affordability-related variables, men were significantly less likely to receive a disability grant (AOR, 0.48; 95% CI, [0.36, 0.63]), and among acceptability-related variables men were significantly less likely to judge the length of queues to be too long or the cleanliness of the facility to be substandard (AOR, 0.69; 95% CI, [0.52, 0.91], and AOR, 0.67; 95% CI, [0.46, 0.97], respectively). Overall, our findings suggest that there is no association between the level of adherence to TB treatment and gender. Moreover, there was no evidence of systematic gender-based disparities in access to TB services. However, the findings reveal concerns about the condition and cleanliness of health facilities that may impact the patients' adherence and be a barrier, specifically, in women's use of TB services.

Introduction Worldwide, an estimated 16 million adolescents fall pregnant annually among these; at least three (3) million have unsafe abortions performed. Similarly, in sub-Sharan Africa more than 50% of the pregnancies in adolescents are unintended and of those, more than half of them end in unsafe abortions (Susheela Singh and Jacqueline E. Darroch &amp; Darroch, 2012). 24% of adolescent females get pregnant annually in Uganda, and most of these are unwanted and unintended pregnancies (Atuyambe et al., 2015). These statistics indicate a problem of unmet need for contraception in Uganda, more so among adolescents, and this calls for more impact studies around adolescent unmet needs for contraception if the problem is to be meaningfully mitigated. Methods An explorative quantitative secondary data analysis study was conducted to determine the unmet need for contraception and its determinants among adolescent girls in Uganda, based on 2011 Ugandan Demographic and Health Survey (UDHS) data. Results Focusing exclusively on female adolescent’s aged 15- 19 years (n= 541), STATA software logistic regression was done to test a model on factors that are significantly associated with unmet needs in the target population of the study. A third (30%) of the study population reported having an unmet need for contraception; the study also revealed that the educational status of an adolescent girl was statistically significant (p=0.002) and related to unmet needs. Married adolescent girls were four times more likely to have unmet needs than those who were never in a union (OR=4.63; 95% CI: 2.06-10.39; p<0.001). Likewise, those adolescent girls who reported living with a partner were twice as likely to have a higher unmet need compared to those having no partners (OR=2.83; 95% CI: 1.30-6.16; p=0.009). Conclusion Any efforts to address the unmet need for contraception among adolescents in Uganda would need specific attention on factors influencing the uptake of family planning services, education, marital status and place of residence being key determinant factors.

Bibliography: leaves 100-103. / The use of Insecticide Treated Nets (ITNs) has already proved to be a cost effective way of malaria vector control. The important emphasis now should therefore be on how to increase the accessibility and utilization of the mosquito nets through devising viable financing and promotional mechanisms that are sustainable and equitable in the long run. One way of financing ITNs that has been propounded by the Roll Back Malaria (REM) has been the issue of the reduction or elimination of tariffs and domestic taxes on ITNs and their inputs. The purpose of this study was to look at how and in what way this RBM financing policy on eliminating tariffs and domestic taxes on ITNS and their inputs would benefit the consumer given the complex nature of ITN industry operations and the consumer behaviour. The study concentrated on information gathered from net manufacturers and insecticide providers, wholesalers and retailers and some key personnel in the overall ITN industry to gather information on production, sales and marketing trends. The analysis revealed that there are indeed gains to be realized by both the consumer and the private sector if tariffs and taxes are removed, in terms of the increase in demand and supply of the product. The elimination of the 15% tariff on ITN input prices in Zimbabwe, ceteris paribus, would lead to the retail price of ITNs falling by between 4% and 12%. This would result in consumer purchases increasing by between 2% and 11%. The elimination of both taxes, other things constant, would lead to the price falling by between 4% and 23 %, leading to retail purchases increasing by between 2% and 21%. Depending on the price elasticities of demand and supply, the fall in retail prices and the consequent increase in retail purchases are quite substantial in a developing country context where incomes are very low. Sensitivity analysis using different demand and supply elasticities also showed that the elimination of tariffs and taxes on ITNs and their inputs would lead to a substantial fall in retail purchases resulting in retail purchases increasing.

This study assessed the health service utilisation costs of untreated maternal depression in women early in their pregnancy in Khayelitsha, South Africa. In addition, it determined the costs of providing treatment or support to these women through a psychological intervention that was delivered by trained community health workers. This thesis was a sub-study of the AFFIRM study (Africa Focus on Intervention Research for Mental Health) whose main objective was to determine the effectiveness, acceptability, cost-effectiveness and potential sustainability of a task-shifted psychological intervention offered to depressed mothers. To determine the costs of maternal depression, health care costs were analyzed over a period of 3 months from both patient and provider perspectives; this information was obtained from participants during their first antenatal visit. These health service costs (excluding antenatal and well-baby visits) were compared between psychologically distressed pregnant women with different severity levels of depression; no depression, mild depression and moderate/severe depression. The cost of the task-shifted intervention was calculated from a provider's perspective and compared to the costs of the 'enhanced usual care' that was offered to women in the control arm. The main costs that were analyzed were the costs of screening, start-up costs, costs of the rooms and recurrent costs. Sensitivity analyses were conducted to determine the robustness of the study results. The results show that as the severity of maternal depression increases, the use of health services also increases. The health service utilisation costs among women with moderate/severe depression ($128.27 per mother/child pair per 3 month period) were almost seven times those of women who did not have depression ($19.70 per mother/child pair), amounting to a mean cost difference of $108.57. For the intervention, salaries, followed by screening costs were the major cost drivers, with screening costs amounting to $26.69 per mother screened positive. Assuming the intervention was delivered to completion without loss to follow up, the cost per mother for the intervention was $230.47 in comparison to $69.93 per mother for enhanced usual care. A sensitivity analysis showed that the screening costs were sensitive to the prevalence of maternal depression. From this study, it can be concluded that women with maternal depression use more health services and incur higher health care costs. It is possible to provide support to these women using psychological approaches that are delivered by lower level staff such as community health workers. This treatment can be affordable, depending on the budget constraints.