Health systems for the 21st century.

Health systems for the 21st century will have to respond to many challenges. This article indicates, against the background of health for all, which factors, both from within and outside, will influence health systems and what approaches and strategies are needed to address them. A strong emphasis will be placed on the government and its ministry of health. By improving the impact of its activities and interventions, by influencing the policies of other sectors and by creating partnerships for health, governments and the ministries of health should become real leaders for health.

User charges for health care: a review of recent experience.

This paper reviews recent experiences with increases in user charges and their effect on the utilization of health care. Evidence from several countries of differences in utilization between rich and poor is presented, and recent accounts of sharp, and often sustained, drops in utilization following fee increases, are presented and discussed. Fee income, appropriately used, represents a small but significant additional resource for health care. Recent national experiences appear to have concentrated on achieving cost recovery objectives, rather than on improving service quality and health outcomes. Appraisal of financing changes must be linked to probable health outcomes. Successful large-scale experience in linking these two is in short supply.

Cost-effectiveness of immunization programs in Colombia.

PIP: An investigation was done to estimate the cost per immunization contact for routinely available vaccination services in Colombia, and to compare these figures with the incremental costs for the additional immunization contacts resulting from the 1984 National Vaccination Campaign. Some 636,000 doses of DPT were given to infants during the campaign's 3 vaccination days. Nearly 190,000 infants received a 3rd dose of DPT on those days. Approximately 98,000 infants began and completed their DPT immunization schedules on the vaccination days. % of infants covered, however, remains uncertain. Infant coverage in 1983 was around 42-44%. The coverage survey showed 66.7% of the infant population covered with DPT by the time of the survey (November/December 1984) but only 50% covered on the actual vaccination days. Infant coverage for polio was 44%, and for measles, 43%. Having national immunization days increased routine immunization program costs by 120%, a substantial amount. In terms of program cost and impact, the national prerequisites for success are probably more related to general development of the necessary communication than to the health sector's physical infrastructure. The national campaign could conceivably eclipse the continuous multipurpose routine services--detracting not only from their immunization efforts but from other preventive and promotional activities.^ieng

Cost effectiveness of potential immunization interventions against diarrhoeal disease.

Estimates are made of the costs per death averted and the costs per case prevented by three possible immunization interventions against diarrhoeal disease in children. These estimates are based on cost information collected from a number of on-going national immunization programmes and from effectiveness estimates reported in previously published reviews. The first part of the paper reviews the state of current knowledge regarding immunization costs and converts data from 9 different studies into a common set of price equivalents. The second section assesses the composition of typical immunization programme costs and estimates the likely effect on existing costs of introducing new vaccines. Compatibility between existing EPI activity and the administration schedule of the new vaccine is likely to be a major determinant of increments in cost per fully immunized child. The third section brings together the cost information with estimates of the likely impact of measles, rotavirus and new cholera vaccines on mortality and morbidity from diarrhoea.

Cost effectiveness of alternative strategies for poliomyelitis immunization in Brazil.

Costs for immunization programs are reported for 16 municipalities in Brazil (January to June 1982). Costs per immunization are higher for all immunizations when given by routinely available, on-demand services. Both intensification of services, in which the medical staff provides outreach immunization clinics, and mass campaign strategies have lower average costs than do the routine services. In the case of immunization with oral poliovirus vaccine, average costs fall from approximately +1.59 to +0.68 (U.S.) when routine and mass campaign strategies are compared. Choice of the most cost-effective immunization policy is shown to involve considerations of vaccine types and target groups as well as delivery strategies and thus involves linking the economic data to epidemiologic considerations (vaccine efficacy and morbidity and mortality levels with and without immunization). Multiple-vaccine programs are likely to have a greater impact per dollar spent than are single-vaccine programs because of the low incremental costs of providing additional vaccinations.

Cost-effectiveness appraisal of immunization programmes.

PIP: This paper describes a cost-effectiveness analysis of the immunization programs in Indonesia, the Philippines, and Thailand, using the program costing guidelines developed for the WHO Expanded Program on Immunization (EPI). The principal organizational features of each program are outlined, and total costs and costs/fully immunized infant are assessed at a small sample of health centers in each country. Costs were found to average US $2.86 in Indonesia, US $4.97 in the Philippines, and US $10.73 in Thailand. At each health center the main element of total immunization costs was fixed, so that average costs/fully immunized child fell as coverage levels and activity rates rose. The implications of this preliminary analysis are considered for each country and common managerial issues in EPI in particular, and primary health care in general, are detailed. Program organization, health care input costs, and population accessibility are considered as explanations of the observed differences in immunization costs. The feasibility of undertaking routine cost-effectiveness monitoring of immunization and other primary health care programs is considered. (author's)^ieng

Cost-benefit analysis and immunization programmes in developing countries.

PIP: Cost-benefit analysis can provide strong evidence of the viability of immunization programs. This form of analysis involves the identification, valuation, and summation of the costs and benefits in each year of the program. The main components of immunization program costs are the wages of the immunizing and supervisory staff, transport costs, and the cost of the vaccine. Major benefits include savings in treatment costs following reduced incidence of disease, reductions in mortality and morbidity, avoidance of suffering to children and their families, and spillover benefits. Although cost-benefit analyses tend to underestimate the benefits of immunization, there is evidence of very high rates of return on investments in this area. This benefit would become even more evident if the benefits derived from a rural infant's immunization were weighted higher than those associated with immunization of urban infants. Moreover, this approach would bring the welfare function in cost-benefit analysis more in line with the aims of policy makers to address inequity in access to health care. Also needing to be addressed are the inadequacies of the human capital approach of life valuation, especially in rural areas of developing countries.^ieng

The economics of pharmaceutical policy in Ghana.

Pharmaceutical expenditure in Ghana accounts for about one-third of the total recurrent costs of the Ministry of Health, but in isolation this figure is a misleading indicator of economic importance. In the primary care sector up to 75-80 percent of the running cost of a health center may be accounted for by pharmaceuticals, and because the Ghanaian currency is heavily overvalued, even these proportions understate the true value of resources used on important drugs. An apparent lack of central control of drugs expenditure led to a study of the existing allocation procedures and prescribing practices. The results suggest large-scale wastage through overprescribing, often in response to patients' preferences for more costly medication. Approaches to improved planning of drug use, including the setting of expenditure norms based on recommended prescribing routines, are detailed, and it is concluded that the resultant savings could allow a sizable extension of the coverage given to rural populations by the primary health care system.

Assessing functional status among elderly patients: a comparison of questionnaire and service provider ratings.

This paper describes a comparative analysis of questionnaire-based measures of functional status and clinical ratings of disability made by general practitioners and health visitors. Both approaches to functional assessment were used in rating 92 elderly primary care patients in terms of their performance of 13 mobility and self-help activities. Simple dichotomous and more complex trichotomous measures of performance were used to summarize functional ability in both the questionnaire and the provider's evaluation. Agreement between questionnaire-based and rater assessments was greatest for less complex mobility and self-help functions in comparisons using both dichotomous and trichotomous scales.

Home treatment in haemophilia: clinical, social and economic advantages.

Twenty-eight severely affected haemophiliacs were observed for 3 months under treatment as hospital out-patients and for the subsequent 9 months while treating themselves at home. Delay in receiving treatment and financial costs were both clearly reduced by home treatment, the patients recovered from individual bleeds more quickly and reported a greater sense of personal freedom and independence. The amount of treatment required did not materially change and no untoward effects were noted; the use of analgesics tended to be less.

Hospital or home care for the severely disabled: a cost comparison.

A case study of severely disabled patients needing regular mechanical help with breathing following poliomyelitis was set up in 1970 to establish what medical, technical, and social support would be required for home rather than hospital care. In this paper these two care alternatives are considered from an economic point of view and a detailed cost comparison is made between entirely hospital based care and predominantly home care.