Background The Sub-Saharan African region has sparse palliative care established to cater for patients facing life limiting conditions. In South Africa, costing frameworks for palliative care interventions for the public sector do not exist and the cost of running a comprehensive palliative care programme remains unknown. There are few costing studies to inform costs of palliative care models which are necessary for decision makers to base their decisions on. The aim of this study was to determine the costs and cost drivers for hospital based consultative palliative care service (HBPCS) in South Africa adopting a providers' perspective. Methods In this empirical costing study, we developed and utilised a costing tool that employed a mixed bottom-up and top-down costing method to estimate the incremental cost of an existing hospital based consultative palliative care services (HBCPCS) in a tertiary hospital in Cape Town, South Africa, called Groote Schuur Hospital (GSH) adopting a public provider perspective. All inputs where valued using bottom-up, ingredients-based methods, except for direct staff where a top-down approach was utilised to allocate the staff's full salary to palliative care services. We collected costing data by conducting inventory audits, key informant interviews and observations. All inputs required in the production of the HBCPCS were checked against a costing framework for economic evaluations of palliative care interventions to ensure that the cost estimates were as inclusive as possible. All inputs with a lifespan of more than one year were annuitized using a 3% rate. Results The total annual cost for running the HBCPCS was R2 494 419 including both recurrent and capital costs. Recurrent items alone accounted for 96% (R2 392 407). While capital items accounted for 4% (R102 013) during the study period. The total cost per visit was R642 including the standard drug treatment package (R16). The major cost driver in the service was personnel accounting or 91% of the total annual cost. While a scenario analysis shows that when the size of the team size is doubled then the cost of direct personnel would increase to R4.4 million. Conclusion We have estimated the incremental unit cost of HBCPCS to be R642 per visit, the major cost driver being personnel. If funding allows, with an annual cost of R2.4 million these services can be provided in a public tertiary hospital as an adjunct to inpatient care for patients as a strategy for integrating palliative care to general health care services, as has been done at GSH. The HBCPCS was less costly when compared to hospital-based outreach palliative care programmes.

Includes bibliographical references.

Bibliography: leaves 93-97. / While in sociology, choice and equity have always co-existed; this has not been a subject of attention in the health care market. Following promotion of the public- private mix in the health care sector, there have been concerns that the pursuit of efficiency might compromise equity in accessing health care services. The main concern for this study was that the resulting relative health care resources distribution following public-private interaction has equity implications at the household level. Kampala district in Uganda was used to investigate this concern. Data collected from a household survey, key informant interviews and secondary data on health care resources distribution, was analyzed using STATA statistical package. The study findings indicated that the private health care sector in Uganda has grown in size and that it caters for more people in Kampala district than the public health care sector. The findings further indicated that households use private services due to the perceived high quality of services, availability of drugs, availability of doctors and other health workers and the nearness of private providers. On the other hand, public health services where used or preferred was due primarily to availability of doctors. Other findings indicated that there was a relationship between provider choice/use and the distribution of health care resources particularly; health workers and health care facilities. This applied both at household level and geographically. Utilization of health services also varied with distribution of the same resources. Private provider use was not solely dependent on income and hence ability to pay, but on other factors related to service characteristics such as perceived quality. The findings further show that there are inequities in financing health care services with low-income groups paying relatively more than high- income groups. The study proposes to policy makers a monitoring mechanism of the variables and outcome measures, both at household and sectoral level, in order to minimize inequities in access to health care. The study also recommends that a comprehensive regulatory framework needs to be set up to promote and control the activities of the private health sector in Uganda.

Includes abstract. Includes bibliographical references.

Includes bibliographical references (leaves 84-90). / Understanding the pricing behaviour of medical providers in private clinics is important for the effective regulation of the private sector and ensuring that there is no extortion of patients. There is a global trend to encourage delivery of health services by the private sector reducing the public role to stewardship. Understanding the factors that influence the price of medical services in an out of pocket setting is important in designing strategies necessary to control the price of medical care. The study investigated the factors that influenced the price of medical services in Kampala district, Uganda. The respondents reported cost of drugs given to patients (type and dose of drug), other overhead expenditures, type of disease, income status of the patient and need to make profit as factors which influence the price of medical services. On regression analysis, it was found that rent was a significant factor on the price of medical services across all disease conditions. It was concluded that governments need to put in place effective regulatory mechanisms to ensure proper functioning of the private health sector.

Includes bibliographical references. / Mother-to-child-transmission (MTGT) of HIV is one of the tragic consequences of the HIV pandemic, There are antiretrovirals for the prevention of mother-to-child-transmission (PMTCT) and Nevirapine (NVP) is the cheapest, most feasible and highly cost-effective of all and suitable for resource poor settings. Voluntary Counselling and HIV Testing (VCT), known for its effectiveness in behavioral change, is also essential for the prevention of mother-to-child transmission of HIV and for the control of HIV/AIDS. Family Health International and Ghanaian MOH intend to implement a prevention of mother-to-child-transmission in the Kassena-Nankana district using VCT and NVP. The success of the use of VCT and NVP for the prevention of mother-to-child-transmission of HIV depends on new effective and sustainable they are implemented and patronized. The purpose of this study therefore is to assess household willingness to pay for VCT and NVP for the prevention of mother-to-child-transmission of HIV in the Kassena-Nankana district of northern Ghana to provide insights into how the impending programme can be implemented sustainably .

Includes bibliographical references. / Like most developing countries, Uganda works on a very tight health budget and the government has to ensure strict principles of efficiency and equity in the allocation and use of the minimal resources. One of the strategies in the process of improving delivery of public services has been to decentralise them. The district local government is responsible for the planning process, data management, resource allocation and co-ordination with the central government. However the capacity of the districts to stick to the principles of efficiency and equity is not a given. In Uganda, the health system has been further devolved with the creation of health sub- districts. Because there are no clear guidelines from both local and central governments on how to ensure equity in resource allocation at the district level there have been arguments that resources from the centre to the district are not necessarily equitably allocated at the sub- district. The principle of equity that would seem of relevance in this case is that of providing resources to those in most need (most deprived) given the minimal resources available. This study was done to assess how health resources are allocated between sub-districts relative to the level of need/deprivation in each sub district and in the process suggest a resource allocation formula for the district. Using mainly data from a rapid household hold survey and simple additive averaging to aggregate variables to create a deprivation index, the study showed that three sub-districts in Luwero district differed in the level of deprivation and the most deprived sub-district was actually under-resourced. The study therefore showed that there is room for using simple indices in a resource allocation formula at the district level so that budgets in the future are allocated to the most deprived areas hence maintaining the central government goal of ensuring equity in the use and allocation of minimal resources that are usually available.

Includes bibliographical references / Background: Pharmaceuticals are responsible for a substantial percentage of the total cost of health care and continue to exceed economic growth and inflation. Generic medicines play an important role in limiting this expenditure, and consequently there is an international drive to implement pro - generic policies particularly in high income countries. One such policy is generic medicine reference pricing (GRP). Generic reference pricing sets a fixed maximum reimbursement amount for clusters of bio - equivalent drugs without placing any restrictions on the manufacturers' price. Numerous studies have been conducted in high income countries to analyse the impact of generic reference pricing; however, the impact of this reference pricing in low - to - middle income countries (LMIC s) is not well established. Objective: This dissertation aims to address this lack of information in LMICs by providing empirical aggregated claims data on the impact of generic reference pricing on price, expenditure, utilisation and out - of - pocket (OOP) p ayments in a sector of South Africa's private health insurance industry. Methods: This time series intervention study of retrospective claim - level secondary data analyses the impact of one of several generic reference pricing models applied by various private medical insurance companies in South Africa. Criteria applied for the selection of referenced categories and sample claims data intend to maximize the data set as well as the analysis period, while minimizing confounders such as medical insurance member variation and specific managed care policies. The impact of the reference price on variables of drug price, drug expenditure, market share and out - of - pock et payment is measured by analysing changes in the originator, 'authorised generic' ('clone') and generic drugs within each cluster. (An 'authorised generic' (AG) is an exact copy of the originator, approved as a brand - name drug under a patent protection but marketed as a generic.) Results: Two referenced priced categories (Desloratadine and Clopidogrel) and a population of approximately 100,000 were identified as being eligible for inclusion. An authorised generic was launched for Clopidogrel but not for Desloratadine. The implementation of generic reference pricing appears to have had no or minimal impact on the price of the originator and authorised generic - at the end of the study period the price of the originator drugs of the two categories was 268% and 86% higher than the reference and the authorised generic of Clopidogrel was 69 % higher than the reference price. Most often the reference price appeared to be based on the price of a generic drug; however once the reference price was set other generics tended to align at or below the reference price. The implementation of generic reference pricing was associated with an overall increase in dispensed volumes and a decrease in expenditure for both categories; both categories' originator market share declined dramatically by volume (to 23% and 4%) and value (to 35% and 9 %). For Clopidogrel the authorised generic took the majority of market share (63% by volume and 68% by value); the generics only gained one third of the market, despite lower product prices and minimal co - payments. Desloratadine generics captured 80% of the market by the end of the study. For both categories there was no notable change in the total drug expenditure paid out - of - pocket across the study period. The percentage of drugs dispensed that had a co - payment decreased dramatically for Desloratadine, but were only seen to decrease marginally for Clopidogrel. Limitations: Due to the small sample and limited reference categories analysed, the findings from this study are not representative of the South African private healthcare sector and cannot be extrapolated to South Africa. In addition, any savings identified should take the expense of non - referenced alternatives into account.

Includes bibliographical references (leaves 114-123). / Zimbabwe has been well known, since independence in 1980, to have one of the best health care systems in Sub-Saharan Africa regardless of a low economic growth pattern. The gains in health status that have been reaped in the 1980s and early 1990s have now been reversed due to the combination of the effects of structural adjustments policies, intermittent drought, a decline in the quality of health care services and severe economic decline. The current economc environment places pressure on households, especially the poorest, to meet the rising costs of individual medical care. The study focused on the evaluation of the patterns and determinants of health care utilization, which can aid in understanding the responsiveness of individuals to the current health care system in light of the economc climate. A detailed assessment of health seeking behaviour and health care utilization was performed using a cross-sectional household community survey comprising of 527 households (2302 individuals) that were randomly selected in three high density suburbs in Harare, Zimbabwe. Information pertaining to demographics, socio-economic status, and health status in addtion to the experiences in the use of health care services or health care providers was collected using a questionnaire.

South Africa is experiencing a medico-legal crisis that is threatening the delivery of essential health care services, especially relating to maternal and fetal health. In the private sector, professional indemnity premiums for obstetricians to provide insurance cover in the event of medico-legal challenges have increased more than 10-fold in a 10-year period. In the State, exponential increases in contingent liabilities for claims due to alleged negligence are usurping health care budgets allocated towards the delivery of health care, with about half of these claims relating to obstetrics and gynaecology and three quarter of latter to cerebral palsy for reasons of alleged hypoxic brain injury of the newborn. Despite the ominous implications of these developments for the supply side of health care, there is a scarcity of information in terms of contributing factors. Whilst many assume that the main driving force of burgeoning professional indemnity premiums for obstetricians and gynaecologists in the private sector have also been as a result of claims for cerebral palsy, there are no empirical data to explain developments over recent years and guide risk management interventions in this regard. To understand claim trends and identify potential predictors of patient dissatisfaction that result in engagement of the regulatory and legal system in the private sector, obstetric and gynaecological medico-legal data recorded by Constantia Insurance Limited, a local professional indemnity provider, were analysed. Other than confirming a steep increase in medico-legal notifications for obstetric- and gynaecology-related complaints from about 2003 to 2012, a high proportion of number of claims and paid settlements for gynaecology relative to obstetric-related cases was noted. This is contrary to international and public sector experiences, where number of demands relating to obstetrics consistently exceed those associated with gynaecological care. This finding, together with the fact that the majority of pay-outs on behalf of doctors related to surgical complications, especially unintended intraoperative injuries to internal organs and vessels, calls for further research into the clinical outcomes of private gynaecological practice, as well as potential review of aspects of surgical training standards and accreditation in gynaecology and consideration of surgical mentorship programmes. The latter is particularly relevant in the context of surgical registrars having expressed concerns about their readiness to practice independently following specialist graduation. Whereas claims for severe neurological injury of the newborn constituted less than 15% of all claims settled on behalf of obstetricians and gynaecologists entered into the study, they accounted for about half of all known paid settlements relating to pregnancy-related care. Whilst not dominating in terms of claim frequency overall, they nevertheless are an important focus area for risk management interventions, given the high quantum of demand typically associated with these cases. In this regard, more research into the etiology of errors is required, including the contribution of nursing and other system failures that could not be quantified adequately as part of this research project. Another important finding was the disproportionate contribution of medico-legal risk by a small cohort of practitioners, which suggests a need for doctor-focused support and interventions, including effective peer review and regulatory oversight by the Health Professions Council. To reverse the high financial burden of professional indemnity fees and fear of litigation amongst private sector obstetricians and gynaecologists, multidimensional risk management interventions, which include enhancements at the point of care, are required. If medicolegal trends and their negative consequences are to be reversed, medico-legal hotspots should become an important source of information and consideration in the development of solutions aimed at preventing human error and strengthening the healthcare system in terms of improved patient safety and satisfaction.