Genital inflammation associated with sexually transmitted infections (STIs) and Bacterial Vaginosis (BV) is considered a key driver in the HIV/AIDS epidemic. A new rapid point-of-care (POC) test that detects genital inflammation in women was recently developed by researchers at the University of Cape Town. The objective of this study was to establish the cost-effectiveness of this novel intervention in comparison to other relevant screening and diagnostic strategies for the management of STIs and BV in women. It follows prior research on the cost and affordability of national implementation of screening with this technology. This research indicated that it might not affordable policy option given current health budget constraints. A decision analysis model was developed to estimate the cost and health outcomes associated with five different screening and diagnostic strategies for women seeking care in the South African public health sector. A decision tree was constructed, and all cost and effectiveness parameters were obtained from published and unpublished literature. The model incorporated all clinic-level and treatment costs associated with diagnosing and treating a single episode of disease. The main outcome measure was the effectiveness of each approach in correctly diagnosing an STI or BV in women, proxied by its sensitivity measure. One-way sensitivity analyses and threshold analysis were conducted to test key uncertainties and assumptions in the model. In the base-case scenario, screening with GIFT and treating GIFT-positive cases based on syndromic management guidelines, was the most cost-effective strategy with an ICER of $2.60 per women diagnosed with an STI(s) and/or BV. This strategy remained the most cost-effective even when a variety of parameters were varied in one-way sensitivity analyses. A threshold analyses on GIFT's sensitivity revealed that the strategy would remain the most cost-effective unless the sensitivity of the test assay decreased below 14.83%. From the perspective of the South African government, screening with GIFT and treating positive cases according to syndromic management guidelines is a highly cost-effective strategy for the management of STIs and BV in women in the reproductive age, but affordability considerations cannot be ignored. The newly developed rapid POC can significantly improve the management of STIs and BV in women through identifying asymptomatic women and at the same time, reducing their risk of HIV infection, but further research is required to inform decision-making.

Includes bibliographical references. / The aim of the study was to determine how equitable allocations to primary health care are, identify the factors that influence allocation and make recommendations on how to promote equitable resource allocation for primary health care in the local government areas of Ekiti state.

Developing countries, while working to achieve the WHO universal health coverage goal, have to constantly strike a balance, when allocating their already limited resources, between health and other sectors of their economies (agriculture, education, infrastructure, housing, security, defence etc..). As a result, there is always a limit on how much funding developing countries local governments are able to allocate to their health sector. Limited heath sector funding in the presence of significant health care needs may in turn have a negative impact on health systems outcomes. In addition to government health financing constraints, health systems outcomes in developing countries may also be jeopardized by the prevalence of inefficiencies within local health care delivery systems, especially within public health facilities. This study investigates the level of technical and scale efficiency of a nationally representative sample of 65 randomly selected public clinics in Eswatini using Data Envelopment Analysis. The DEA estimates indicate that 42 clinics (64.7%) were technically inefficient, with an average technical efficiency score of 80.4% (STD= 18.8%). Fifty-one (78.4%) clinics were scale inefficient with an average scale efficiency score of 90.4% (STD = 6.6%). The most prevalent scale inefficiency among public clinics was increasing return to scale with 92.2% (47/51) of scale inefficient clinics operating under increasing return to scale. All 42 inefficient clinics could have delivered the same level of output with 5,701,449.4, US $ less in government funding, 115.3 less clinical staff, 138.8 less support staff and 119.8 less consultation rooms The results reveal inefficiencies within the Health system in Eswatini. It seems possible to save significant amount of money if measures were put in place to mitigate resource wastages. Hence, policy interventions that help not only optimize inputs but also allow outputs expansion through improving the demand for health care would contribute to improving technical and scale efficiency of public clinics in the Kingdom of Eswatini.

This dissertation assessed socioeconomic inequalities in skilled birth attendance in Zimbabwe. High maternal mortality in low-income countries is a cause of concern globally. Skilled birth attendance prevents a substantial number of maternal deaths and it is critical for ensuring overall maternal health. However, sub-Saharan Africa is characterized by challenges in accessing skilled birth attendance. The existence of health inequalities has been demonstrated when simple comparisons are made by residence (rural-urban), education and wealth (poorrich) in developing nations. The study used data from the Zimbabwe Demographic and Health Surveys (ZDHS) of 2010/11 and 2015. The analysis focused on women of child-bearing age (15-49 years). Skilled birth attendance was determined by women assisted by health personnel with midwife training. Health personnel was defined as a nurse, midwife or doctor. A binary logistic regression model was computed to understand the relationship between skilled birth attendance, demographic attributes and some explanatory variables. Standard concentration curves and Wagstaff normalized concentration indices were used to assess whether skilled birth attendance was dominant among the poor or rich in Zimbabwe. Overall skilled birth attendance prevalence increased for the periods under review. Regression results showed that antenatal care visits, residence status, place of delivery, women level of education, employment status and marital status are statistically significant predictors of skilled birth attendance. Wagstaff normalized concentration indices of aggregated use of skilled birth personnel reflected that wealthy women were more likely to receive skilled birth attendance. The concentration curves for aggregated skilled birth attendance showed minimal existence of health inequalities, as the concentration curves almost coincided with the line of equality. However, a disaggregated analysis by health personnel revealed the existence of health inequalities. In summary, minimal socioeconomic inequalities exist if skilled birth attendance aggregated, but when assessed by different health personnel categories, widening socioeconomic inequalities are observed.

Includes bibliographical references (leaves 113-121). / International recognition of the health problems being faced by developing countries have resulted in significant increases in external development assistance for health since the late 1980s. However, it has been established that this aid has not been effective due to poor coordination, harmonization and alignment. As part of the aid development architecture, donors and recipient countries have defined approaches, modalities and methods of working aimed at improving harmonization, alignment and management of aid for results. One such approach is the Sector Wide Approach (SWAp) which involves ensuring that "all significant funding for the sector supports a single sector policy and expenditure programme, under government leadership, adopting common approaches across the sector, and progressing towards relying on government procedures to disburse and account for all funds." (Foster et ai, 2000a, p.6).In Zambia, the health SWAp has been in existence since 1993. The adoption of the health SWAp was necessitated by a desire to optimize the use of domestic and externally mobilised financial and in-kind development assistance through the integration of all vertical programmes into a sectoral framework that would meet common national goals and objectives. This was after it was realised that the health system was inefficient in its provision of health services due to the existence of fragmented, multiple donor-assisted projects which the Ministry of Health could not effectively coordinate and manage.This paper explores the contribution of the health SWAp to the provision of effective health care in Zambia since its inception in 1993. The study considered the SWAp as both an aid instrument and as a process and the evaluation is made by looking at both the individual elements of a SWAp and the SWAp mechanism as a whole. The study assesses the contribution of the SWAp to fostering working relationships, accountability for finances and progress, efficient allocation and use of resources, financial sustainability and promotion of geographical equity of access to health care resources.The study was exploratory and a retrospective approach was used to track and associate changes before the introduction of the health SWAp and after the SWAp implementation period 1993 - 2005. In order to take account of certain contextual factors in the broad health reform continuum, a combination of qualitative and quantitative research techniques were used. This includes 21 in-depth key informant interviews, a Focus Group Discussion (FGD), non-participant observation at 4 different SWAp coordination meetings and a comprehensive document review. Study participants were senior members of the Health Sector AdviSOry Committee that were drawn from 6 provinces (including the capital city Lusaka). The actual selection of interviewees was done purposively based on the possession of requisite expertise, diversity and availability.

Extending coverage to the informal sector is a key challenge to achieving universal coverage through contributory health insurance schemes. Ghana introduced a mandatory National Health Insurance scheme in 2004 to provide financial protection for both the formal and informal sectors through a combination of taxes and annual premium payments. As part of its election campaign in 2008, the current government (then in opposition) promised to make the payment of premium "one-time". This has been a very controversial policy issue in Ghana.

Includes bibliographical references. / This thesis investigates the implications of fiscal federalism on the equitable distribution of primary health care resources in South Africa. The study evaluates the processes and criteria for intergovernmental and sector budgeting, the influence of key stakeholders, community involvement in PHC budgeting, and policy objectives of the health sector to assess how they impact on the realisation of an equitable distribution of PHC resources. A combination of qualitative and quantitative analyses was employed in the study. Quantitative analysis of health expenditure and health need data was used to assess whether the distribution of PHC resources has become more or less equitable. Health districts were the units of analysis. Deprivation indices were generated using principal components analysis for each district from demographic and socio-economic variables. The deprivation index was used as a proxy for relative need at the level of districts, and was compared with non-hospital PHC per capita expenditure using regression analysis. This analysis was carried out for per capita PHC from 2001 to 2007. Data on the process for intergovernmental fiscal arrangements and budgeting for health was collected through review of government publications and interviews with government officials. These were analysed thematically. Literature on the subject predicts that if lower levels of government have considerable autonomy in determining primary health care allocations, there is a greater scope for inequities in the distribution of primary health care resources. However, the results of the study are contrary to expectations. Although, the introduction of fiscal federalism in South Africa created an additional constraint to achieving a more equitable distribution of PHC resources, recent trends in primary health care allocations are more equitable than in previous years. A growing public sector budget, consistent increases in health sector allocations, and overwhelming political support for equity in South Africa have been the key reasons for the shifts towards a more equitable distribution of primary health care resources. These findings form the main contribution to the literature on the subject.

Includes bibliographical references. / The thesis set out to explore how households cope with the costs of malaria and the implications of malaria cost burdens for household livelihoods and vulnerability. It uses a conceptual framework that takes a holistic approach to understand vulnerability and the link between malaria and livelihood change. In order to investigate these issues, the study was designed to meet five main objectives: to improve the understanding on the economic burden of malaria; to identify factors that make households vulnerable to the costs of malaria; to identify and explore coping strategies; to understand the role of health care providers in aggravating cost burdens and; to inform policy debates on how to improve access to effective malaria treatment and protect households from high illness costs.

Includes bibliographical references. / This research investigates absorptive capacity in South Africa's public health sector in relation to scaling up financing for HIV/AIDS treatment. The thesis constructs a conceptual framework, which follows the flow of public funding for HIV/AIDS treatment. The study combines a quantitative budget analysis, which looks at expenditure and spending patterns, with qualitative in-depth interviews with key stakeholders exploring causes and consequences, which are the main pillar of the primary research. The study applies the conceptual framework nationally, as well as in the Free State and Western Cape provinces. The contributions of the thesis are two-fold: At the conceptual level, the study defines and constructs an analytical framework of absorptive capacity and related bottlenecks in the context of funding for HIV/AIDS treatment in the public health sector. It identifies five major areas where bottlenecks may arise: financial, human, infrastructural, institutional (within the health system) and structural (outside the health system). At the empirical level, the study assesses and compares absorptive capacity and major bottlenecks encountered nationally and in the Free State and Western Cape provinces in respect of the public sector funding for the HIV/AIDS treatment programme. The results confirm that absorptive capacity is not merely about spending funding. Spending should not compromise other programs or elements of the public health system, and it should be efficient, equitable and sustainable. The findings show that South Africa's absorptive capacity was constrained by several obstacles, such as poor practices and a shortage of human resources, insufficient financial capacity and demanding requirements of conditional funding, inadequate infrastructure, and inadequate national leadership. To overcome these obstacles, the mere injection of even more funding would be an insufficient response. Consequently, the study indicates which other reforms are required, including: further integrating antiretroviral treatment services within the public health structures; further decentralising antiretroviral treatment towards primary health care; task shifting; iii balancing the conditional grant and equitable share; and enhancing coordination between the National and Provincial Departments of Health and with Treasury.

Background Rheumatic Heart Disease (RHD) is a disease of poverty that is neglected in developing countries. The consequences of RHD are increasingly becoming huge economic burden to the health system and consecutively the government. Despite RHD being preventable, most of the RHD related deaths happen in children and working age adults where the economic burden of premature death is high. Several strategies have been suggested to advance the escalation of disease severity in order to avoid medical cost including cost of surgery. However, lack of adequate evidence regarding the cost of treating RHD has hindered the needed decisions and interventions to prevent RHD related death. The main objective of this study was to evaluate the utilization of resources and quantify the annual average total cost related to RHD in a tertiary hospital in the Western Cape, South Africa. Methods A mixture of ingredients and step-down costing approaches were used to estimate the annual cost of RHD care from health system perspective. All costs were estimated in 2017 (base year) South African Rand (ZAR) and 3% discount rate in order to allow depreciation and opportunity cost. Data on service utilization rates were collected using a randomly selected sample of 100 patient medical records from the Global Rheumatic Heart Disease Registry (the REMEDY study), a registry of individuals living with RHD. Patient-level clinical data, including, prices and quantities of medications and laboratory tests, were collected from Groote Schuur Hospital (GSH). Step-down costing was used to estimate provider time costs and all other facility costs such as overheads. REMEDY and GSH data were aggregated to estimate the total annual costs of RHD care at GSH and the average annual per-patient cost among REMEDY participants. One-way univariate sensitivity analysis was conducted to deal with uncertainty. Results The total cost of RHD care at GSH was estimated at $2, 238, 294 (ZAR 27 million) in 2017, with surgery costs accounting for 65% of total costs. Per-patient average annual costs, which included outpatient care, cardiac medical and intensive care unit (ICU) care, cardiac catheterisation lab procedures, and heart valve surgery, was estimated at $4, 311 (ZAR 52, 000) per-patient annually. The cost of medications and consumables related to cardiac catheterisation and heart valve surgery were the main cost drivers. Conclusions RHD care consumes a significant level of tertiary hospital resources in South Africa, with annual perpatient costs much higher than many other non-communicable and infectious diseases. This analysis supports the scaling up of primary and secondary prevention programmes at primary health centres in order to reduce the future burden on tertiary services. The study may also inform resource allocation efforts related to RHD at tertiary centres and provide cost estimates for future studies of intervention cost-effectiveness.