There has been growing global attention to Universal Health Coverage (UHC) and countries across the world have placed achievement of UHC amongst their top policy priorities. UHC is defined as ensuring that all citizens can access relevant health services whenever they need care in a manner that ensures they are not exposed to financial hardship. Health financing systems are critical to achieving UHC- one of the building blocks of a health system, health financing is concerned with the mobilization, accumulation and allocation of funds to cover the needs of a population. The purpose of a health financing system is to make funding available, set the right incentives to health care providers and to ensure all individuals have access to effective public and personal health services. A health financing system has three inter related functions; revenue collection, pooling and purchasing which all need to work together for achievement of UHC. Purchasing is defined as the allocation of pooled funds to providers in exchange for medical services. Purchasing can be passive (whereby purchasers simply pay bills presented by providers) or strategic (whereby purchasers continuously apply evidenced based decisions and processes when allocating funds to providers to maximize value). Many countries aiming to achieve UHC have prioritized shifting from passive to strategic purchasing as part of their health financing system reforms. Literature shows evidence that implementation of strategic purchasing can contribute to achieving UHC by: aligning funding and incentives with promised health services to promote access; linking transfer of funds to providers to performance with the goal of promoting quality in service delivery; and enhancing equity in resource distribution. Implementation of strategic purchasing mechanisms is however not a straight forward process as providers can use various sources of power such as: monopoly and bargaining capacity; some provider payment mechanisms such as fee-for-service; and information asymmetry to resist the adoption of strategic purchasing mechanisms. Providers are likely to resist implementations of those mechanisms that they perceive will shift too much of the risk of providing care to them or will erode their economic gains. Purchasers also have sources of power they can use to influence implementation such as: institutional regulatory authority; monopsony and bargaining authority; and some provider payment mechanisms such as capitation. Power in this study is defined as a relation between two parties whereby party A is said to have power over party B to the extent that A can get B to do something that B would not have otherwise done. Kenya has in the past decade formulated and implemented various policies towards achieving UHC, including reforming some of its purchasing functions. An example is the introduction of capitation (a provider payment mechanism) for private providers, by the public purchaser National Hospital Insurance Fund (NHIF). Private purchasers have, as part of strategic purchasing, intervened in clinical decision-making processes amongst private providers as a way of managing costs and improving quality. Existing literature shows public and private purchasers in Kenya are faced with multiple challenges when implementing strategic purchasing mechanisms such as lack of technical expertise, poor planning and resistance from some providers. This study explored the implementation of strategic purchasing mechanisms by NHIF and private purchasers amongst private providers in Kenya to understand the role of various sources of power in influencing implementation outcomes (acceptability and adoption) in order to contribute to work on how to implement strategic purchasing. Private providers in Kenya play a significant role in provision of care and over 40% of facilities in Kenya are privately owned. We employed a multiple case study design. The first case focused on implementation of capitation by the public purchaser NHIF. The second case focused on the implementation of select strategic purchasing mechanisms by private purchasers including intervening in clinical decision-making processes, use of preauthorization and use of specialists for second opinions amongst others. In total eight interviews were completed and eighteen documents(including newspapers articles, documents from websites, and provider-purchaser contracts) were included as data sources. Each case was analysed individually using thematic analysis, after which a cross case analysis was completed. Our findings show that in the first case of the NHIF purchaser, NHIF used its regulatory authority to gazette and hence dictate the capitation rate to providers. NHIF also used its monopsony to convince providers that there would be significant economic gains from the capitation model as NHIF had a huge number of beneficiaries. However, some of the large providers used their monopoly and bargaining capacity to walk away from the scheme as they still commanded significant market share even without the NHIF capitation business as they felt the proposed capitation rate was too low. In the second case, private purchasers used contracts as a source of power to give them some authority to control prices of services and ensure providers adhered to strategic purchasing mechanisms such as use of preauthorization processes. Some private providers on the other hand used various sources of power to resist implementation such as information asymmetry to by-pass some of the documentation requirements set by the private purchasers. Some providers also used monopoly and fee-for service payment mechanisms to dictate prices of services to purchasers. Some private providers did however willingly adopt some of the strategic purchasing mechanisms namely: preauthorization processes and use of step-down facilities as they felt these minimized the risk of unpaid claims. Across the two cases, NHIF seemed to have had relatively more power over providers compared to private purchasers. For example, NHIF gazetted the capitation rates and did not revise them despite strong opposition from some of the large private providers, whilst private purchasers complained that some of the large private providers always had their way by dictating prices of their services to the private purchasers. Whilst there have been a growing number of recent studies touching on strategic purchasing in Kenya, few of them have focused on the role of power and/or implementation of strategic purchasing in Kenya. This study focused on how various sources of power for providers and purchasers can affect implementation of strategic purchasing in order to provide insight into the implementation of strategic purchasing mechanisms. The study found that private providers can use their various sources of power to resist adoption of strategic purchasing mechanisms they do not deem acceptable; some mechanism are however deemed acceptable and are willingly adopted. The study also highlights that purchasers can use their sources of power to influence adoption of strategic purchasing amongst providers. The study hopes to provide insight to policy makers and purchasers on the need to consider the role of power when implementing strategic purchasing mechanisms and to plan accordingly. One general lesson on implementation includes the importance of early communication and dialogue when implementing strategic purchasing mechanisms.

Includes bibliographical references. / Severe acute malnutrition is one of the leading underlying causes of mortality in children under the age of five years. Nearly one to two million child deaths worldwide can be attributable to this illness. Although it is considered to be a global public health issue, severe acute malnutrition imposes an uneven burden on health resources across the world, with low-income countries shouldering much of this burden. Like any illness, severe acute malnutrition imposes an economic burden on households that, if significantly large could result in the impoverishment of households. However, despite the existence of a large volume of literature on the intergenerational economic consequences of malnutrition, little is known about the short term household economic consequences of malnutrition. This mini-dissertation sets out to estimate the household economic burden imposed by severe acute malnutrition in children under the age of 5 years in Zimbabwe. Furthermore, it aims to investigate and evaluate household responses to the economic consequences of malnutrition and the effect of the responses on household economic welfare.

In Kenya, an intervention to improve the quality of care of children was developed and tested in district hospitals. This was a multifaceted intervention employing clinical practice guidelines, training, supervision, feedback and facilitation, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. This thesis presents an economic evaluation of this complex intervention.

Includes bibliographical references. / [Objectives] In Nigeria, free antiretroviral treatment (ART) centers are mainly located in urban and peri-urban areas despite higher HIV-prevalence in rural areas. This study investigated the socio-economic and socio-demographic characteristics together with the access barriers faced by the users of free ART in Enugu State, southeast Nigeria. [ Design ] Cross sectional study Methods The study was conducted in two purposively selected sites/facilities (one public and one private) administering free ART. In each of the two facilities, 120 patients living with HIV/AIDS (PLWHA) were interviewed. Information about socio-economic status, demographic characteristics, factors constraining access and coping mechanisms were elicited using interviewer-administered questionnaires as a patient came out of the doctor's consulting room (exit interview). Principal components analysis, frequencies and cross tabulations were used in analysis. [ Results ] Of the 240 respondents, 67.5% were female. The mean age of the respondents was 36 years and 46.7% were within the age range of 30-41 years. The main occupations of the respondents were petty trading (21.3%), artisan (20.0%) and government worker (19.2%). High cost of transport (32.5%), stigma (31.7%) and long waiting hours (23.3%) were found to be major hindrances to accessing free ART. The mean cost of transport was US$3.94 per visit although an SES analysis showed that the most poor incurred the highest cost of transport (US$5.48) per visit. Stigma is clearly more of a barrier in Enugu metropolis (49%) compared to communities outside the Enugu metropolis (18.6%) and states apart from Enugu State (22.2%). PLWHA spent an average of 3.39 hours at the clinic during their monthly appointment. Own savings and financial support from relatives were the main coping mechanism used for accessing free ART. The most poor (underprivileged) bore a higher cost of transport while the effect of stigmatization appeared to be felt by all the socioeconomic groups. [ Conclusion ] Potential findings indicate that the poor bear the highest burden of transport costs while stigmatization affects all socio-economic groups although more on non poor than the poor. Advocacy against HIV and AIDS related stigma is crucial if HIV/AIDS interventions are to achieve their desired outcomes. Concerted effort is required from government, non-governmental agencies, communities and religious groups in the campaign against HIV/AIDS related stigma. The key finding of high traveling costs, particularly for the poor, suggests the need to consider mechanisms that might enhance access for the rural poor such as mobile ART clinics. It is also imperative to employ more medical personnel so as to address the issue of long waiting hours experienced by users of free ART.

The aim of this study was to evaluate the implementation of exemptions and waivers and to support efforts to address current challenges and promote use of public sector health services. The study was conducted in Bagamoyo and Mtwara rural districts. A qualitative approach (in-depth interviews and focus group discussions) was used since it was considered appropriate for a study focusing on the perceptions, views, and experiences of users and providers.

Socioeconomic inequalities in health have received significant attention globally because of the well-known association between wealth and health. A lot of studies show that poor people are more prone to sickness than their counterparts. Immunisation has been a key antidote to avert deaths for children under the age of 5. This study represents an initial attempt to assess specific variables that contribute to socioeconomic inequalities in immunisation coverage in Zimbabwe. Data were obtained from the 2015 Zimbabwe Demographic Health Survey, a nationally representative survey. Immunisation coverage was measured using four categories: full immunisation (a child who will have received 10 doses of vaccines), partial immunisation (a child who will have received at least one but not all vaccines), no immunisation (a child who will not have received any immunisation dose from birth) and immunisation intensity (a proportion of doses received to total doses that they should have received). Inequalities in immunisation coverage in Zimbabwe were assessed using concentration curves and indices. A positive (negative) concentration index indicates immunisation coverage concentrated among the rich (poor). The concentration index was decomposed to identify how different variables contribute to the socioeconomic inequality in immunisation coverage in Zimbabwe. Results indicate that immunisation intensity and full immunisation concentration indices were (0.0154) and (0.0250) respectively, indicating that children from lower socio-economic status are less likely to receive all doses of vaccines. No immunisation and partial immunisation concentration indices were (-0.0778) and (-0.0878) indicating that children from higher socioeconomic status are more likely to have their children immunised opposed to their poor counterparts. The main contributors to socioeconomic inequality in immunisation coverage are the mother's education, socioeconomic status and place of residence (rural/urban and province). While immunisation services are free of charge in the public health sector in Zimbabwe, coverage rates are higher among the wealthy, which shows that there may be barriers to utilising these services that may not be the direct cost of vaccination. There have to be measures by the government to reach people in areas that are not easily accessible. Also, more needs to be done to reduce socioeconomic inequalities in Zimbabwe.

Includes bibliographical references (leaves 105-122). / The purpose of this study was to measure health inequity amongst a cohort of HIV positive mother-child pairs in South Africa with a focus on the relationship between household socio-economic status and child health outcomes. This study is a secondary analysis to a prospective cohort study of mothers and infants participating in three of the eighteen national PMTCT sites in South Africa. Women (and their infants) were recruited prior to, or at the time of delivery and followed until the infants were 36 weeks of age. Three sites were purposefully sampled in order to reflect different socio-economic regions, rural-urban locations and my prevalence rates. The study made use of principal component analysis (PCA) to measure household socio-economic status. The selection of both variables that are indicators of socio-economic status and the use of PCA as a technique of assigning of weights to the chosen indicators of socio-economic status was informed by the literature. The selection of health outcomes was based on the renewed focus on child health. This study is organized in five chapters. The first chapter provides the rationale for measuring inequities in child health with particular focus on South Africa and states the aim and objectives. Chapter Two reviews different forms of literature that were pertinent in understanding the importance of child health, the current state of child health and the relationship between inequities and poor child health outcomes. Chapter Three gives a detailed discussion of the data collection and quality control methods employed to achieve good quality data in the primary study. Then it discusses choosing indicators of socio-economic status and intricacies involved in measuring socio-economic status. In addition, it outlines the chosen child health outcomes, motivation for their choice and their measurement.

Includes bibliographical references. / The control of tuberculosis (TB) in South Africa has fallen short of the targets outlined by the World Health Organization and without improvement; TB is expected to have grave consequences for both the mortality and morbidity of South Africans as well as crippling financial consequences for the public health system. While services in the public sector are free at the point of use, little is known about overall access barriers and their implications for treatment adherence. This paper explores these barriers from the perspective of TB patients enrolled in Directly Observed Treatment, Short-Course (DOTS) in Mitchell's Plain, South Africa. Using a comprehensive framework of access, in-depth interviews were conducted with 334 TB patients across five facilities in Mitchell's Plain, to assess barriers across the dimensions of availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between adherent and non-adherent groups, and between socioeconomic groups were explored using bivariate, multivariate linear and logistic regressions. Among the respondents, 244 (73.05%) met the criteria for adherence (i.e. reported that they had never missed a dose of TB medication) while 90 (26.95%) met the criteria for non-adherence. Marital status, age, birth province, costs of self-care and costs of other providers were found to be significantly associated with adherence (P-values <0.05). There was no significant evidence of inequalities in access by socioeconomic status (all P-values > 0.05). Nonetheless, the results revealed that the poor face increased costs of accessing TB-services, compared to the rich, though this association was not deemed to be significant.

HIV co-infection and drug resistance worsen the burden of Tuberculosis in South Africa. Infectious TB cases, often undiagnosed and untreated, are commonly found in health facilities increasing the likelihood of health-care associated TB. Health Care Workers (HCWs; and clients) are particularly at risk of TB infection in health care facilities; such risk characterises TB as a dual public health threat; first as a communicable disease and second as an occupational health hazard. Tuberculosis infection control (TBIC) measures may reduce the risk of TB transmission in health care settings, yet HCWs face challenges implementing TBIC measures. There is a gap in operational research seeking to understand the barriers to TBIC implementation among HCWs. There is, therefore, an urgent need to generate qualitative data, using a behavioural and sociological approach that provides insight to TBIC implementation challenges among HCWs. This case study research explored the barriers to TBIC implementation among HCWs in Khayelitsha clinics. Among professional and lay HCWs, data was collected by direct observation, interviews, focus group discussions and review of previous TBIC clinic assessment reports. The data was analysed using thematic analysis and interpretive analysis. This minor dissertation is in four parts. The protocol (Part A) presents the concept note of the study and its methodology. A structured literature review (Part B) provides a background and broadly reviews previous research and findings on Tuberculosis infection control. The journal ready article (Part C) presents the study findings, while Part D presents the study tools and related resources (appendices). Although most HCWs recognise the importance of TBIC in preventing health-care associated TB, they commonly believed that the TB transmission risk is only significant in clinic areas where known TB patients are found, and as such emphasise TBIC measures in those areas. Measures such as use of respirators and masks are mostly prioritized by HCWs ahead of administrative and environmental measures that are potentially more effective in reducing TB infection. Barriers to TBIC implementation identified include: inadequate HCW training on TBIC, a non-responsive compensation policy and the perception that a busy clinic schedule leaves no time for TBIC implementation. Resource availability, adequate human resources and leadership were further identified as enablers for TBIC implementation.

Basic immunisation coverage for children between 12-23 months in Zambia was 68% in 2013. Nevertheless, a substantial number of child deaths persist as a result of preventable disease. This study assesses the relationship between women empowerment and immunisation coverage in Zambia. It also investigates socio-economic inequality in full, partial, and immunisation intensity. Thus, the findings will support improved immunisation coverage, especially for those who are the poorest in Zambia. The study uses the 2013-14 Zambia Demographic and Health Surveys (ZDHS), which are nationally representative household surveys [12]. This dataset incorporates information regarding children from 0 to 59 months and for men and women aged 15- 49 years old. The two main study variables are women empowerment and immunisation. Immunisation was divided into three categories namely, full, partial and no immunisation. Concentration indices are used to assess inequality in full, partial and no immunisation coverage as well as in the intensity of immunisation coverage. Briefly, a positive concentration index means that immunisation coverage is pro-rich as richer children are more likely to be immunised. A negative index indicates the opposite. The main finding of this study was that socioeconomic status has a significant impact on the immunisation coverage of a child. For children who were fully immunised, immunisation was found to be pro-rich (concentration index = 0.046). The distribution of partially immunised children (concentration index = -0.114) and not immunised children (concentration index = -0.138) is pro-poor. This confirmed that poorer women were more likely to have a partially immunised/not immunised children compared to a child whose mother is richer. Immunisation intensity had a pro-rich outcome (concentration index = 0.153). In addition, the study confirmed the importance of household decision making as a determinant of a child's likelihood of being fully immunised (p-value< 0.01). This study has shown that close attention to factors such as women empowerment and a mother's education can support improved immunisation coverage, especially for those who are the poorest in Zambia. This paper further highlighted the importance of socio-economic status as it impacts on immunisation coverage.