Bibliography: leaves 90-98. / Although, malaria is a major problem in Ghana, as III many Sub-Saharan Africa countries, there has been little research on its economlC impact, particularly at the household level. National statistics only show that malaria accounted for more deaths, more cases and more potential days of life lost than other cause, however little was said about the costs to households. The aim of the study was to estimate the economic costs (direct and indirect) of seeking malaria care to households and in doing this, the study used data collected from a randomly sampled 423 households in K-N district. Malaria was ascertained not by parasitological test but through self-reporting based on symptoms described by respondents using a one-month recall period. The estimation of direct cost involved the out-of-pocket expenditure on special foods, drugs, transportation, diagnostic and consultation and all other related costs (e.g. inpatient cost, toiletry cost, etc.). Indirect cost was estimated based on the number of days forgone and waiting time incurred due to malaria episode or caretaking and daily wage rate. The estimated costs were divided between direct and indirect costs, and examined in terms of location and case severity. Total direct cost per case in urban area was ¢6,701 ($1.79) compared to ¢7,822 ($2.09) in rural area. With regards to severity, direct cost per severe malaria was ¢11,182 ($2.98) compared to ¢5,317 ($1.42) of mild malaria. In the case of indirect cost and with regards to days lost, the average duration of severe malaria was 5.3 days, which was significantly higher when compared to 2.3 days of mild malaria. Estimated indirect cost per case in urban area was ¢20,804 ($5.55) compared to ¢15,842 ($4.22) in rural area. In terms of severity, 55% of the days lost were due to severe malaria and women in general lost more days and often incurred higher losses in potential earnings than men.

Objective: The aim of this review is to analyse quality improvement interventions at the primary care level. Quality improvement interventions attempt to close the gap between clinical research and practice. The objectives of this review are to identify, synthesise and evaluate research literature relevant to primary care regarding quality improvement interventions; as well as identify the enabling and constraining factors impacting quality improvement at the primary care level. Design: This review involved a qualitative, systematic review of previously undertaken qualitative research. Data sources: Data was sourced from electronic databases PubMed and CINAHL. Study selection: Articles were selected based on their relevance and published in English in an academic journal between June 2001 and June 2011, using qualitative data collection and analysis methods to assess a quality improvement intervention at the primary care level. Data extraction: Data was extracted from the articles' 'findings' and 'discussion' sections. Data synthesis: 110 articles were identified, 11 of which were included. Thematic analysis occurred in three stages: line-by-line coding, creation of descriptive themes, and creation of analytical themes. Conclusion: Interventions aimed at quality improvement in primary care do not experience uniform ease of implementation. It is possible to create the conditions necessary for success by harnessing human capital; creating a nurturing, supportive and collaborative working environment; and providing inspirational leadership through management.

The impact of the HIV pandemic in Tanzania has been profound and has affected all sectors. Today, HIV/AIDS is recognized not only as a major public health concern but also as social, economic and development problem in Tanzania as in most in Sub-Saharan African countries. With a population of estimated 37 million, Tanzania has an estimated of 2.5 million people infected with human immunodeficiency virus (HIV). The availability of antiretroviral therapy (ART) which has been defined as the main form of treatment (yet not a cure) for HIV/AIDS showed to significantly prolong and improve quality of life of people infected with HIV. By and large, the entire range of antiretroviral drugs is available anywhere in the world through private channels. Where resources permit, the supply may be adequate and consistent. Through the public sector, however, and for low-income patients, the choice of drugs may be somewhat restricted. This has implications for decisions such as when to start therapy, which therapeutic regimens to use, and what to do when treatment fails. The situation requires difficult choices in priority setting, poses serious ethical issues and imposes on government the obligation to scale up programmes in ways that are ethically sound, equitable, beneficial and sustainable as possible (WHO 2004). However in Tanzania, there is no clear policy established on targeting or prioritising specific population groups in order to avoid decision making based on subjective or arbitrary criteria that may lead to discrimination. The aim of this study was to establish the socioeconomic status of those individuals who benefit most from the provision of free ARV in terms of utilisation in urban and rural settings. It also aimed to identify the criteria used in enrolment of patients for free ARV provision, the barriers for ARV provision and patient's perception on ARV.

Includes bibliographical references. / Deafness affects about 15- 26% of the world’s population with an estimated prevalence of 3.7% in South Africa. Although sign language Interpreters (SLIs) improve the communication challenges in health care they are unaffordable for many Deaf people. On the other hand, there are no legal provisions in place to ensure the provision of SLIs in the health sector in most countries including South Africa. However, to advocate for funding of such initiatives, reliable cost estimates are essential and such data is scarce. To bridge this gap, this study estimated the costs of providing such a service at the District health services level based on estimates obtained from a pilot-project that initiated the first South African Sign Language Interpreter (SASLI) service in health-care. The ingredients method was used to calculate the unit cost per visit at the SASLI Project level from a provider perspective. The average SASLI utilisation rate was calculated from the projects records for 2008-2013. Sensitivity analyses were carried out to determine the effect of changing the discount rate and personnel costs. The unit costs per SASLI-assisted visit were used in estimating the costs of scaling up this service to the District Health Services. Average utilisation rates increased from 1.66 to 3.58 per person per year from 2008 -2013 with unmet need falling from 38.8% in 2008 to 10.8% by 2013. The cost per visit was R2074.80 in 2013 whilst the estimated costs of scaling up this service ranged from R143.6million to R775million in the Cape Metropole District. These cost estimates represent 2.4%-12.8% of the budget for the Western Cape District Health Services. The results show that in the presence of SLIs, Deaf SL users utilise health care service to a similar extent as the average population, however this service would requires significant capital investment by government to enable access to healthcare for the Deaf.

Includes bibliographical references. / The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003 with the aim of mobilizing additional funds for health care, promoting equal access to reasonable health care, pool health risks, prevent impoverishment, and improve the efficiency and quality of health care. The success of the NHIS in improving access to health care since its implementation and the extent to which it has impacted on health seeking behaviour has not been extensively investigated. This study examines health-seeking behaviours of insured and uninsured households on the mutual health insurance scheme on health care access in the Kassena-Nankana District (KND) of northern Ghana and to determine the factors that influence household decision to enrol into the NHIS. The study is a cross sectional survey of 422 household heads randomly selected to represent rural, peri-urban and urban zones of KND. Data was analysed using STATA version 8.0. A binary logit model was used to determine factors that predict household enrolment into the NHIS. The choice of a particular type of provider with multiple outcomes was analysed using a multinomial logit model. Results showed that 72% of household heads were males and the average age was 51 years. Out of the 422 respondents, 64% were insured. Household heads of age 40 years and above, being a female household head, being married, and economic wealth positively influenced enrolment into the national health insurance scheme. Seventy four percent (74%) of the ill among the insured and 48% among uninsured sought care from public facilities while 14% among the insured and 8% among uninsured sought care from private facility. Also, self treatment among the insured was 13% and 44% among uninsured households. Results also showed that being a member of NHIS and being moderately or severely ill were associated with public health facility utilization. Household heads of 60 years or older was negatively associated with use of public health facilities. Similarly, a household that was insured, being a Muslim and the severity of illness of household member were positively associated with the use of private health care. The findings showed that the insured were more likely to use formal care providers than the uninsured. This implies that the NHI in the KND has improved the health seeking behaviour from the hitherto use of informal providers and self treatment to preferred use of formal providers.

Includes abstract. / Includes bibliographical references. / Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by investigating the research objectives through a combination of quantitative (cross-sectional household surveys) and qualitative (Focus-Group Discussions) analysis of the gendered impact of OOPs on health care access in south-eastern Nigeria.

Includes bibliographical references / Patients diagnosed with rifampicin resistant (RR) tuberculosis (TB) in South Africa frequently fail to link to appropriate drug resistant (DR) TB treatment. The aim of this study was to explore barriers and enablers to expedited linkage to treatment following RR-TB diagnosis in the Western Cape Province, within the context of ongoing decentralisation of DRTB services and the scale-up of Xpert MTB/RIF diagnostics. Methods: An embedded case study approach, using qualitative research methods, was employed to explore barriers and enablers to expedited treatment linkage following RR-TB diagnosis. The case of investigation in this study was 'treatment linkage following RR-TB diagnosis in the Western Cape Province during the ongoing decentralisation of DR-TB services and scale-up of Xpert diagnostics'. DR-TB is used in this study as an encompassing term to refer to RR, multidrug resistant and extensively drug resistant TB. The embedded units of analysis in this study were patients' linkage outputs, defined as: (1) expedited treatment initiation, (2) delayed treatment initiation and (3) non-initiation of treatment following sputum collection on which RR-TB was diagnosed. Seventeen patient, 8 family member, 49 healthcare worker and 4 key informant open-ended, in-depth interviews were conducted and 59 patient folders were reviewed. Additionally, an extensive literature review was conducted. The tools used for data collection in this study were developed from the literature review and Coker et al.'s (201) conceptual framework for evaluation of a communicable disease intervention. A framework approach using Coker et al.'s conceptual framework was applied for analysis. Results: This study identified multiple factors that enabled and constrained expedited treatment linkage following RR-TB diagnosis. Enabling factors included: 1) the availability of clinic level DR-TB counsellors and tracers; 2) living in walking distance of decentralised services and 3) having a strong social support network. Constraining factors included: 1) low usage of Xpert diagnostics, 2) delays in acting on results and missed (or unseen) results, 3) rotation of nurses or the lack of dedicated TB nurses in clinics, 4) limited clinic-level administrative support, 5) information systems challenges and 6) waiting lists for beds and limited access to transport services in rural areas . In linking to treatment, patients commonly face challenges due to competing subsistence needs and household or employment responsibilities. Additionally, substance addiction, having a history of treatment interruption, hopelessness regarding treatment, as well as not having a stable place to stay or social support may increase patients' risks of linkage failure. Conclusion: Within the Western Cape Province, there is significant opportunity to improve linkage to treatment through strengthening the health systems mechanisms to link patients to treatment following RR-TB diagnosis. Expanding access to psychosocial services (substance abuse rehabilitation and psychosocial evaluations) following RR-TB diagnosis may assist in linking high-risk patients to treatment. Additionally, the provision of food support (in addition to social grants) should be evaluated as a tactic to improve treatment linkage and adherence.

Bibliography: leaves 96-99. / Health reforms that advocate for more private sector involvement in the provision and financing of health services are increasingly being considered as a means of ensuring more efficient provision of health related services. Though such reforms may be designed, funded and implemented it does not imply that the conditions necessary for them to yield the intended results do exist. One such reform is contracting out. The only national referral hospital Uganda has a long history of contracting out health support services, but there is hardly any empirical evidence of the resultant efficiency gains. To study the contractual arrangements in the hospital a theoretical framework based on what determines contract performance was used as the basis for the analysis. Several methodology approaches were used, which included in-depth structured interviews with the hospital administrator and key government officials on the entire contractual process and to establish the regulations and policies underlying the contracting out policy in the country. In addition a detailed documentary review was done for the contract design and implementation and other issues pertaining to the cleaning and security services. Cost data was obtained from the hospital’s expenditure and accounts records. Quality of the services data was collected using a quantitative interview schedule that required consumers to indicate their satisfaction with the security and cleaning services when they are provided in-house as opposed to when they are provided by contractors. One of the major findings is that while it was cheaper to provide cleaning services through contracting out, it was actually more costly to provide security services through contracting out than in-house provision. Therefore there is no clear pattern to support the hypothesis that health support services can be provided at a lower cost than direct provision of services. This is because contract costs are a function of service complexity, contestability and management capacity. Services that are hard to specify involve uncertainty about the nature and costs of production itself, which is likely to increase total contract costs both during contract negotiations and the post contract stage. Secondly, contractors had succeeded in providing better quality services than in-house provision. One pertinent issue of contract design is that is key to contract success is the detailed specifications of the expected outcome in terms of both quantity and quality for this greatly eases the enforcement and monitoring process and is likely to a positive impact on the quality of services that the contractors provide, for both parties will have a clear picture of what was expected. The study highlights a number of factors that contribute to the success of contracts: First, governments needs cost and quality information on its own services for this should be the basis upon which decisions to contract out should be made. Secondly, award and renewal of contracts requires regular and detailed evaluation of provider performance and of the market situation especially in low contestability and competition. Thirdly, there is need to have incentives within the management of contracts efficient monitoring. Lastly, contract failure was attributed more to the government bureaucratic and centralised systems that often resulted in delays in awarding contracts and paying contractors.

Includes bibliographical references. / This research presents a partial economic evaluation of the current and anticipated impact of widespread antiretroviral treatment on the secondary hospital system in South Africa. The evaluation encompasses the treatment and care of HIV -positive inpatients and outpatients on or preparing for highly active antiretroviral therapy (HAART) at the secondary level. This study was conducted based on analysis of the Antiretroviral Referral Unit at GF Jooste Hospital during March 2005, and utilises a combination of current and retrospective data sets.

Bibliography: leaves 50-51. / In the late 1980s, many governments in the low-income countries could not fund their health care budgets adequately due to poor availability of fmancial resources. This resulted into deterioration of the public health sectors in general. Inadequacy of consumables and other supplies, and low payment for health workers were among the problems faced. Governments in some of these countries introduced public private mix (PPM) to address these problems. In 1996, the government of Tanzania allowed private practice in public hospitals called 'the fast track' service. This study investigated the organizational and management system of this type of PPM, its impacts and the factors determining people's demand for the fast track service. Data was collected through interviews with health care providers and patients, and document reviews. Systematic and random sampling methods were used to select participants. Data was analysed using STAT A package. The study found that the executive directors of the hospitals headed the fast track management teams, with the executive committees coordinated by the executive secretaries. The committees included specialist doctors involved in the PPM. The study findings also show that about 85% of health care providers reported that the practice played an important role in supplementing the hospitals' budgets as well as health workers' incomes. In one of the study hospitals, the "fast track" services contributed more than 26% of the total income during a 5-year period. Likewise, it has significantly improved the access to health care services. This was achieved through retaining health workers, improving the infrastructure, adequate supply of consumables and drugs, and raising funds to subsidise treatments for poor patients. However, the fast track services resulted in specialists spending less time with public patients. In addition, the standards of private care were still lower in the "fast track" when compared to what is expected in a private health care setting, and private patients were offered very poor diagnostic tests and investigation services. Concerns were also raised about the poor management of the funds generated from private services.