Includes bibliographical references. / In Malawi, sputum smear microscopy (Ziehl-Neelsen) is a major diagnostic technique for pulmonary tuberculosis (TB). Though relatively rapid, it tends to be poorly sensitive since it requires a large number of organisms to be present in the specimen before they can be detected. Two approaches that improve sensitivity of direct smear microscopy are sputum liquefaction with chemicals such as sodium hypochlorite (household bleach) and subsequent concentration with gravity (natural) sedimentation and centrifugation. This study estimated the costs and cost-effectiveness of these techniques in processing sputum for detecting new cases of pulmonary tuberculosis in Malawi. Bleach natural sedimentation and bleach centrifugation methods were compared with direct smear microscopy. Cost and effectiveness data were collected from a randomized controlled trial from one major TB health facility. Effectiveness was determined by number of smear positive TB cases detected by each method. Cost-effectiveness was estimated from a provider's perspective in terms of cost per TB cases diagnosed and cost per smear positive TB case detected. Cost per positive TB case detected was least in natural (gravity) sedimentation (US $9.35), compared to centrifugation (US $11.48) and direct smear microscopy (US $15.93). The study findings indicate that natural sedimentation can significantly reduce cost of sputum processing. There is a strong economic case supporting the use of natural sedimentation for diagnosing tuberculosis in Malawi. In addition, bleach digests sputum making it less infectious and easy to work with thereby increasing the safety of specimens to clinicians. Therefore, introducing natural sedimentation technique would not only reduce costs but also improve safety to health workers.

Includes bibliographical references (leaves 95-103). / Most low-income countries have not been able to fulfill the health care needs of the poor, and especially the rural population. Budgetary and other resource constraints in the health sector have been the major causes of this failure. Tanzania, like any other poor country is faced with challenges in health care financing, such that it cannot provide adequate cushion against health care costs for the majority of its population. One response to this situation was the health care financing reforms which among others saw the introduction of voluntary Community Health Fund (CHF) in 1996. The aim of the CHF was to mobilize resources through collection prepayments from households on a voluntary basis to fund primary health care for people in the informal sector operating in rural areas. However, CHF membership (enrollment) has been reported to be below the targeted coverage of 85% of the population living in rural areas. The percentage of households joining CHF has been ranging from 4% to 18% in various districts. This low enrolment prompted the need to study the predictors of and barriers to enrolment in CHF.

Bibliography: leaves 113-118. / The Malawian sector spent about 3.3% of its GNP on health services in 1995/96. The public sector alone spent about 6.2% of its total revenue on health services and this is much high than most other Sub- Saharan African countries (e.g. Zambia, Kenya, Uganda). Despite such high levels of public expenditure, Malawi’s social and health indicators are among the worst in the world. The majority of the Malawian population suffer from a large amount of preventable illness and premature death which could be treated/prevented by simple inexpensive medical interventions. This scenario raises questions with regard to the government stated priority to primary health care and preventive health services. This investigation therefore was undertaken in order to quantify the total health care expenditure in Malawi and its distribution and then evaluate its equity and efficiency implications for the delivery of health services. The analyses focused on the public health sector due to the fact that the public health sector is the largest provider of health services in Malawi and its services are fiee of charge. It was therefore felt that a detailed analysis and evaluation of this sector could go a long way in improving the health status of the majority of Malawians within the resource envelope.

Includes bibliographical references. / The need for health care financing mechanisms that are progressive in Zambia cannot be over-emphasized. It is necessary that health care financing mechanisms are in such a way that they are related to ability to pay. This is an equity objective. This is the main motivation for this study. It is envisaged that this study will provide empirical evidence on the progressivity and determinants of OOP payments. This information is important for policy making regarding health care financing.

As the drive towards universal coverage is gaining momentum globally, the need for assessing levels of financial health protection in countries, particularity the developing world, has increasingly become important. Swaziland's health financing system performance in terms of ensuring financial health protection is not clearly understood. This paper assesses financial catastrophe and impoverishment from out - of - pocket payments and associated factors that predict them in Swaziland. The Swaziland Household Income and Expenditure Survey (SHIES) for 2009/2010 was used for the analyses. Financial catastrophe was assessed using a variable threshold. Impoverishment was assessed using both a national and $1.25/day international poverty line. Logistic regression models were used to assess factors that predict household vulnerability to financial catastrophe and impoverishment. It emerged that about 9.6 per cent of the Swazi households experienced financial catastrophe while about 1.1 per cent were pushed below the poverty line as a result of out - of - pocket payments. Factors associated with households' vulnerability include; education of the household - head, household size, location, age and household socio - economic status. The findings indicate that financial health protection is not adequate in Swaziland. Thus, there is a need for financing mechanisms that do not place undue hardships on the poor and vulnerable.

Bibliography: leaves 83-89. / Unofficial fees are a common feature in Ugandan health facilities and exist in different forms. This study explores the forms of unofficial fees existing in Ugandan hospitals and compares findings from government and non-governmental hospitals in both rural and urban areas. It also investigates the reasons for or causes of such fees as well as the relationship between unofficial fees and other factors such as quality of care within the hospitals. The overall aim of the study is to analyze the magnitude and impact of unofficial fees on patients' expenditure and thereby make recommendations for improvement in efficiency and equity with regards to out-of-pocket funding. Both qualitative and quantitative interview methods are used to obtain data from service providers and patients in each hospital and a comparison of findings obtained using the two methods is made. The main findings from the study are that unofficial fees are rampant in government hospitals and can be classified into four categories; fees for commodities such as drugs; fees for access to services; fees for services such as laboratory, radiology and surgery and gratuity payments. The latter category is the commonest form reported in non- government hospitals while all the others are rare. Estimates of unofficial fees amount to a significant percentage of patients' expenditure, especially in the cases where surgery and radiology are required especially for rural-based patients. It's also found that most of the patients attending government hospitals pay at least one form of unofficial fees. Unofficial fees were found to be closely associated with poor quality of care in that the latter enhanced an informal economy, which resulted in the fees being charged/paid. The study shows that efficiency and equity (access to quality care and ability to pay) are negatively affected by the practice of collecting unofficial fees. Recommendations for policy makers to address the problem are made as well as suggestions for the best-suited methodology for analysing unofficial fees in the Ugandan context.

Strategic purchasing is a way of ensuring that the healthcare interventions that are provided, improves the health systems responsiveness. Contracting for health services, as a component of strategic purchasing, has been promoted as an important mechanism to improve the efficiency of resource use, quality in health care service provision and increase accountability, all of which contribute towards improving health system performance. Over the past two decades, many countries have adopted contracting as a mechanism to positively impact the performance of the health system. However, despite the increasing interest and experimentation with contracting as a way to improve health systems, the results remain controversial. Within South Africa's private healthcare market, medical schemes represent the largest source of private healthcare funding. Given the rate of increase of medical inflation within the South African private healthcare market, there is an absolute need for medical schemes to become more strategic in their purchasing decisions. This dissertation aims to address the gaps identified in the contracting literature by providing empirical evidence from an evaluation of a contractual agreement between a healthcare financing agency, medical scheme, and a managed care organisation in the private health sector in South Africa for the provision of a back rehabilitation programme to reduce the cost of back surgeries. The dissertation also attempts to formulate key learnings that will inform future policies regarding contracting for healthcare services within the private and public health sector in South Africa.

Includes bibliographical references (leaves 119-124). / Community-Based Health Insurance Schemes are new forms of health financing that can increase resources available for a national health system. These schemes are often regarded as not feasible. Evidence from recent experiences however; show that , if they are appropriately designed and managed they can be feasible and sustainable. The successes achieved by such schemes in Ghana motivated the government to make them a mandatory system of health financing. The main objective is that every resident of Ghana shall belong to a health insurance scheme that adequately covers him or her against "cash and carry" (i.e. user fees) in order to obtain access to a defined package of acceptable quality needed health services without having to pay at the point of receiving service. This study sought to undertake a critical comparative study of the performance of voluntary and mandatory community health financing schemes in Ghana and assess their prospects and challenges in their effort to improve efficiency, equity and the schemes' sustainability. The study, a qualitative one, employed descriptive survey techniques to evaluate the ability of schemes to finance their activities from their own sources and mechanisms put in place to cater for the poor and vulnerable, i.e. to evaluate with sustainability and equity respectively. The study also considered control measures to minimize cost escalation to assess efficiency. Focus group discussions, key informant interviews and document reviews were used to examine performance of voluntary and mandatory schemes in meeting those criteria. The study found that both voluntary and mandatory schemes were not self-sustainable due to low coverage and inadequate funds mobilized by the schemes. The main reasons for the general low enrolments are poverty, poor quality health service and limited benefit packages. The study showed that including out-patient (OPD) services in the benefit package and quality improvements in health service improve members' acceptability of insurance hence increase membership rates which will eventually increase schemes' sustainability. Efficient and effective administration of risk equalization fund will help reduce differences in districts' ability to raise revenue owing to different levels of economic activities as well as local morbidities. The study showed further that small community-based health insurance schemes (CBHIS) could be sub-district level financial intermediaries for the District Health Insurance Schemes. It was found in this study that a practical means testing mechanism to declare one poor in order to quality for exemption from contribution should be adopted. The study also suggests that alternative reimbursement mechanisms to fee-for-service need to be considered. The study suggests further research on equity in access and means testing. Such study should consider coming up with mechanisms for identifying the very poor in the communities and to put in place workable and sustainable measure to tackle the financial barriers to health care they face.

Equity in health care financing and progress towards universal health coverage (UHC) have increasingly received recognition and growing attention for their potential to improve health outcomes globally. However, most low income countries and in particular those in sub-Saharan Africa which have borne the greater share of global disease burden have had relatively lesser success in their endeavours to improve their health care financing systems. It is only a few that have made considerable progress towards universal health coverage. Zambia, a developing country struggling with income inequalities and poor progress to achieving universal health coverage, is no exception. The current discussion on countries moving toward universal health coverage, however, requires an understanding of the impact of the prevailing health care financing mechanisms on income distribution. Investigation of an overall income redistributive effect of health care financing thus requires assessing health care financing in relation to the principles of contributing to financing health care according to ability to pay. Zambia is currently considering major health systems reforms toward a universal health system. Health care financing system in Zambia is however faced with numerous challenges that must be addressed prior to meeting this goal. To promote the goal of achieving universal health coverage, there is a need to measure the extent of the redistributive effect of the current health care financing mechanisms. This allows identifying which health care financing mechanisms provide financial protection and promote universal health coverage in the country. With this growing focus on the goal of universal health coverage (UHC), health care financing mechanisms should not only relate to who pays and who receives the benefit, but also to their effects on income distribution. This is because financing of health care may have redistributive effects and equity consequences. This income redistribution may be intended or unintended. Even in the latter case, policy makers may be interested in the degree to which it occurs. This is because it has consequences for the distribution of goods and services other than health care and, ultimately, for welfare. This study investigates the extent to which the current health care financing in Zambia redistributes income, particularly whether or not it reduces income inequality. The study seeks to evaluate an overall pattern of income redistributive effect of the current health care financing mechanisms. It specifically assesses the income redistributive effect of two broad health care financing mechanisms; general tax and out of pocket (OOP) payments. Using a standard procedure for analyzing income redistribution of health care financing in Zambia, the study decomposes the income redistributive effect of each of the two broad health care financing mechanisms into the vertical, horizontal and reranking components.

Includes bibliographical references. / The objective of this study is to measure health worker motivation in a South African context. Sout Africa is a middle income developing country. Health workers consume up to 60% of public health budgets in South Africa, and yet unlike many developing countries, it is possible that resource re-allocation may lead to some drastic changes in health workers' motivation.