This project assessed the cost and cost-effectiveness of hypertension management in South Africa within the context of a text messaging-based intervention (StAR* study) conducted in an urban public-sector clinic in Cape Town. The StAR* study is a community randomized trial that investigated the effect of adherence support via short messaging service (SMS) on treatment adherence and patient outcomes for the management of hypertension at Vanguard CHC in Cape Town (Bobrow et al. 2016). Patients received behavioral text messages as reminders for them to collect and take their medication on time. The StAR* study, consisted of three arms that ran in parallel: participants in the control arm received unrelated messages; patients in the information-only arm received one-way information messages twice a week; and patients in the interactive arm received interactive SMS-texts at the same frequency as those in the information only arm (Bobrow et al. 2016). Patients in the interactive arm could respond to the messages and trigger a response from the healthcare provider. The text messaging based intervention was shown to improve hypertension outcomes over a 12-month period in hypertension patients by improving adherence and retention in care. The study showed, in the one-way intervention arm an improvement in adherence (measured by medication refill rates) and a small reduction in systolic blood pressure (2.2mm Hg reduction over 12months) (Bobrow et al. 2016). In this study, we assessed the cost and cost effectiveness of the StAR* intervention under routine care management at Vanguard CHC. We also assessed the cost of hypertension management from the health system perspective and the cost of accessing hypertension care from the patient perspective. A combination of the ingredients approach and step-down costing was used to cost hypertension care from a health system perspective while a questionnaire was administered to 250 patients to estimate patient costs. The primary outcomes were the average cost of hypertension care and the incremental cost of the text message-based adherence intervention (StAR* intervention), compared to usual care, per millimetre of mercury (mmHg) reduction in systolic blood pressure. Results of the study show that the average health system cost for hypertension management is R262 per visit and the patient cost of accessing hypertension care is R172 per visit. The text messaging based intervention was found to have low implementation costs in this pilot phase. The monthly incremental cost of the text messaging based intervention cost was R4 per person. The incremental cost-effectiveness ratio of the intervention was R22 per mm Hg reduction. This study provides the first contemporary assessment of hypertension management costs and the cost-effectiveness of mobile-based hypertension adherence support in South Africa. Future work will seek to estimate the long-term cost-effectiveness of this intervention and the cost of scaling it to the provincial and national levels.

archives@tulane.edu / 1 / Lu Yao

Includes bibliographical references / This thesis uses the National Income Dynamics Study (NIDS) data to estimate the extent of, and the factors correlated with, socio economic related health inequalities in South Africa. We extend our analysis by investigating whether income has a causal effect on health outcomes. The thesis is divided into four separate, but related chapters. In chapter two, we describe the data and the variables used in the study. We then check the quality of health related data in the NIDS by analyzing attrition trends and establishing whether attrition affects the representativeness of the data in subsequent waves. We use three health outcomes, self-assessed health, body mass index and depression, to test for the potential effects of attrition bias on parameter estimates. We test using the attrition probit and Becketti, Gould, Lillard and Welch (BGLW) tests, which are two well-known tests for attrition bias in panel data. We find that although the attrition rates of individuals from the sample are high in wave 2 and 3 (21% and 20% respectively), their attrition is random with respect to the health outcomes we use. In chapter three, we establish the socioeconomic factors correlated with health outcomes in South Africa. We use bivariate and panel data approaches. We find significant correlations between health outcomes and socioeconomic factors (income, educational attainment, and demographic factors). Income is positively correlated with self-assessed health and body mass index, and it is negatively correlated with depressive symptoms. In chapter four, we build on the findings discussed in chapter three to estimate the extent of Income Related Health Inequality (IRHI). We estimate the index of inequality using a health concentration index. We then decompose the concentration index to establish the extent to which the correlates of health outcome drive the IRHI. The panel nature of the data allows us to investigate whether IRHI is narrowing or widening. We find a positive health concentration index. This implies that better health is concentrated among the rich. The decomposition of the index reveals that these differences are explained by disparities in income and educational attainment. We also find that the IRHI has narrowed from 2008 to 2012. Most of the narrowing is unexplained but about 21% and 20% of the decrease is correlated with the changes in the distribution and response to covariates respectively. One of the socioeconomic determinants identified from the previous chapters to be correlated with health is income. In the last part of this thesis, we extend the analysis to investigate whether this relationship is causal. To do so, we use the Old Age Pension (OAP) programme as a natural experiment. The OAP is based on age eligibility. Therefore, we use this age eligibility as an exogenous income shock to isolate the effect of income on health. We apply a Regression Discontinuity Design on the NIDS data to identify this effect. We do not find any contemporaneous effect of income on three health outcomes considered, namely; self assessed health (SAH), body mass index (BMI), and depression.

No description available.

As nations are encouraged to move towards achieving Universal Health coverage (UHC), access to essential medicines needs to be prioritized. In ensuring access to medicines, an important factor to be considered is the uninterrupted availability of essential medicines at the primary health care (PHC) level which is usually the first point of entry into the health system for patients. If South Africa is to move towards achieving UHC, the government must address the issue of unavailability of medicines due to frequent stock outs at the public health facilities. The increase in prevalence of HIV/AIDS and TB has resulted in an increase in the demand for medicines used in the management and treatment of these diseases. Surveys have revealed the extent of stock outs and shortages of medicines used in the management of HIV and TB in South Africa. It has also been predicted that the burden of disease in relation to these diseases is likely to increase in the coming years therefore, it is important for the South African government to address the issues of stock outs. Using a qualitative multiple case study approach, we explored the factors which may influence the management of medicine stock thus causing medicine stock outs at four PHC facilities in two of the districts in the study province. A conceptual framework on the factors influencing medicine stock outs at health facilities was developed from reviewing literature on the subject and this was used to guide data collection and analysis. Our findings revealed that the factors influencing the management of medicine stock leading to medicine stock outs include the lack of capacity in terms of human resources and physical resources at the PHC facilities. Insufficient supervision and support from the district level also had an influence as health workers at the facilities did not always follow the recommended procedures for medicine stock management. We also found that there were gaps in communication between the health workers at the facilities and stakeholders at other levels, particularly the pharmaceutical depot from which the facilities obtained their medicines. The inadequate information systems contributed to this gap in communication. Whilst many studies have focused on the factors that may influence the availability of medicine at higher levels, this study focused on what may influence it at the ground level, the PHC facility level. We anticipate that our findings will inform policy makers on how the availability of medicines at PHC facilities may be improved by focusing on improving the processes in medicine stock management at this level.

Introduction: The cost of ART remains amongst the most prevalent barriers to treatment, especially in resource limited countries where many people are poor and inadequately covered by private and public health insurances. This study aims to assess the financial consequences of out of pocket payment for ART in the South African setting and the ability of couples to financially recover. Methods: A prospective follow-up study was carried out at the Infertility Clinic of the Reproductive Medicine Unit, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town. All 135 participants from the original study were invited to participate with no exclusion criteria. A six part questionnaire, developed for the original study, was adjusted to assess recovery from out of pocket expenditure for ART. Indicators of recovery included the recuperation of savings, settlement of debt and reacquisition of sold assets. Persistence of coping strategies such as reduction in spending and additional work was also assessed. Results: A follow-up rate of 54% percent was achieved. The minimum and maximum follow up period was three and five years respectively. Nineteen percent of couples reported complete financial recovery, assessed as the recovery of savings, repayment of all debt and recovery of a sold asset. Forty percent of couples were unable to settle their debt incurred during the original study. The average amount still owed was R 7 750 (SD R5 140). At follow up, 75% of couples who had reduced expenditure to offset the original cost of ART were still reporting a reduction in expenditure while 39% were still engaged in additional work. The majority of couples reporting difficulties at the time of follow up in paying bills or for basic amenities and healthcare were from the poorest socioeconomic tertiles with 64% of all couples indicating that they were not coping financially at the time of follow up. Conclusion: This study documented a long-lasting impact of OPP for ART among all HH but especially among the poorest. Given the high prevalence of infertility, its impact on individuals, couples and communities, the associated mental, emotional and financial consequences, and existing barriers to adequate and affordable treatment should be minimised as South Africa is moving towards the implementation of a national health system.

This dissertation studies the effect of political stability on health outcomes and expenditure in the SADC region. The health outcomes under investigation are life expectancy at birth, maternal mortality ratio, infant mortality rate and HIV incidence. Health expenditure is captured as the percentage of total government expenditure that is allocated to public health. The study conducts a literature review on previous studies that examine these relationships, conduct exploratory data analysis and conduct empirical estimations using two measures of political stability: International Country Risk Guide’s Political Risk Services index and the World Bank’s World Development Indicator index. Additionally, further investigation is made into the effect that a country’s level of democracy has on health outcomes and public health expenditure. The empirical estimations involve a panel dataset containing 11 SADC countries over a 20 year period from 1996 to 2015. The results confirm the statistical and economic significance of political stability on all the health outcomes under investigation and on public health expenditure when controlling for heteroscedasticity and autocorrelation. Holding all else constant, a one point increase in the political stability variable is associated with an increase of 0.19% for life expectancy, a decrease of 1.39% in maternal mortality, a decrease of 2.01% in infant mortality, an increase in HIV incidence of 3.48% and an increase in public health expenditure of 2.03%, when using the International Country Risk Guide’s Political Risk Services index (ICRG). Political instability in the SADC region is characterized by destruction of social infrastructure including hospitals and roads in Angola and the Democratic Republic of Congo and lack of resources for adequate healthcare in countries such as Zimbabwe, Zambia and Malawi. Both mechanisms result in poor health outcomes in a given country in the region. Subsequently, countries like South Africa receiving refugees from politically unstable countries in the region also suffer from an overload on their health system which means resources allocated to the health sector are no longer adequate to meet the increased demand. When using the World Bank’s World Development Indicators (WB), holding all else constant, infant mortality decreases by 0.27% and HIV incidence increases by 0.40% when political stability increases by one point. The policy recommendation is to ensure strategic governance is in place to ensure that the health sector is not affected by political instability.

The health benefits of a national household electrification programme are investigated. Cognisance is taken of the lack of utilisation of electricity by newly electrified households. The impact of electrification on air pollution levels and paraffin utilisation is investigated to establish the effect on morbidity due to respiratory infection, paraffln poisoning and bums. The reduced demand for health services stemming from a reduction in morbidity is quantified and its macroeconomic implications investigated. The implications that the results of this quantification process holds for the financing requirements of a national household electrification programme as well as the microeconomic factors underlying the success of such a programme are highlighted. Chapter 1 outlines the methodology that will be used to firstly establish the expected switch to electricity as sole energy-carrier by newly electrified households, secondly to establish the health implications of such a switch, and thirdly to quantify these health implications. Chapter 2 reports the results of the modelling exercise, chapter 3 the resulting health implications and chapter 4 the quantification process. Chapter 5 looks at the macroeconomic implications of the health benefits of electrification. Chapter 6 investigates the impact of the results of this thesis on the financing requirements of the electrification programme. Bibliography: pages 63-68.

Health services utilisation, which is sometimes used as a proxy measure for equity is a complex subject to study. Identifying and explaining the important factors determining health care utilisation is a key to a better assessment of whether countries' health policies address the equity concerns of their populations in a comprehensive way. It is extensively documented that meeting the health needs of people especially those disadvantaged by such factors as geographical location, joblessness, low income, gender inequalities and lack of education among others, is an important strategy to preventing the increase in poverty and eventually reducing equity gaps. Realising this goal is not easy unless studies are done to establish policy and theoretical arguments related to why some sections of populations are more likely to use/or not to use available health care services than others. This cross-sectional study principally aims at assessing the impact of perceived quality and costs of health care on utilisation of PHC services in rural and urban areas of Tanzania. Using both quantitative and qualitative methods, it intends to explore whether there are differences between rural and urban users in terms of their perceptions of quality of health services and how these perceptions affect household decisions in utilising health services. It further examines the extent to which costs of health care are important determinant in health services utilisation and how rural and urban users are affected by this factor when it comes to deciding to use or not to use government health facilities. The study concludes that consumers of health care in rural Tanzania are highly responsive to health care costs than they are to quality concerns. As the two categories of rural and urban are affected differently by costs and their perceptions of quality when it comes to health care utilisation, it is possible that the observed utilisation trends can partly be attributed to these two factors. Furthermore, the study highlights that socio-economic variables such as gender, income, education, wealth and household size are important not only in determining user's decision making on the amount and appropriate time to seek care but also mitigates effectively on the extent to which costs and perception of quality of care affect rural and urban users of health care services. The study recommends that the government should strive to provide better "quality " information to its consumers. It further recommends that a critical evaluation of important quality aspects be done to see which mostly determine household decisions on utilisation of care among rural and urban users of care. The study has found that the kit system has had some problems, hence the study recommends that government devises mechanisms of ensuring that drugs are available at points of service. Acknowledging the existing geographical inequities, the need to incorporate the private sector in PHC provision and improve quality of health care, the study recommends for more resources to be devoted to research and venture on new opportunities provided by the ongoing reforms as a way of introduction, chapter one of the study report presents the country background information and how the health system is organised. The remainder of the report is organised as follows. In chapter two, the report presents the literature review whilst chapter three covers conceptual framework and methodology. This is followed by presentation of results and analysis in chapter four before putting forward a brief discussion of the findings in chapter five. In chapter six, conclusions and policy recommendations are presented.

The specific objective of this report is the assessment and analysis of the current financial management capacity at the district level in Mount Frere. It will specifically address the assessment and analysis of financial management capacity in the Mount Frere district, Region E in the EC Province, Department of Health.