Costing essential services package provided by a non-governmental organization network in Bangladesh.

The health profile of Bangladesh has improved remarkably, yet gaps in delivering quality health care remain. In response to the need for evidence to quantify resources for providing health services in Bangladesh, this study estimates unit costs of providing the essential services package (ESP) in the not-for-profit sector. This study used a stratified sampling approach to select 18 static clinics, which had fixed facilities, from 330 non-profit clinics under Smiling Sun network in Bangladesh. Costs were estimated from the providers' perspective, using both top-down and bottom-up methods, from July 2014 to June 2015. In total, there were 1115 observations (clients) for the 13 primary care services analysed. The estimated 2015 average costs per visit were: antenatal care ($7.03), postnatal care ($4.57), control of diarrheal diseases ($1.32), acute respiratory infection ($1.53), integrated management of child illness ($2.02), sexually transmitted infections ($4.70), reproductive tract infections ($3.56), tuberculosis ($41.65), limited curative care ($4.30), immunization ($2.23), family planning ($0.72), births by normal delivery ($29.45) and C-section ($114.83). Unit costs varied widely for each service, both between individual patients and among clinic level means. The coefficient of variation for the 13 services averaged 66%, implying potential inefficiencies. In addition, 32.9% of clients were not offered any lab test during the first antenatal visit. The unit cost of essential services differed by the type and location of clinics. Ultra clinics, on average, incurred 37% higher costs than vital (outpatient type) clinics, and urban clinics spent 40% more than rural clinics to deliver a unit of service. The study suggests that inefficiency and quality concerns exist in health service delivery in some facilities. Increasing the volume of clients through demand-side mechanisms and standardization of services would help address those concerns. Unit costs of services provide essential information for estimating resource needs for scaling up the ESPs.

Modelling the returns on options for improving malaria case management in Ethiopia.

BACKGROUND: Diverse opinions have emerged about the best way to scale up malaria interventions. Three controversies seem most important: (1) should the scale-up focus on a broader target of febrile illness (including infectious disease and pneumonia)? (2) should the scale-up feature a single intervention or be targeted to the situation? (3) should scale-up have a preference for one kind of delivery mechanism or another? METHODS: A decision model of 576 nodes describes the patterns of access, treatment and outcomes of an episode of febrile illness for a child below 5 years. Incremental costs and outcomes relative to baseline (2010) are computed for particular scenarios for Ethiopia using data from the literature. Two perspectives define the relevant costs: society at large and financiers (government and donors) where the costs borne by households are not included. FINDINGS: Scaling up malaria interventions by one means or another is a very inexpensive way of saving young lives in poor countries. The low cost per life saved stems from two main reasons: the excessive baseline costs of presumptive use of antimalarial drugs for non-malaria cases, and the excessive costs of delayed treatment of pneumonia. A very limited policy of supplying antibiotics to facilities to eliminate stockouts would save 2100 lives, at a cost of only $615 a life. A much broader programme option, bundling malaria and pneumonia together for patients presenting with febrile illness [including rapid diagnostic test (RDT) for malaria, respiratory rate timers (RRTs) and free antibiotics], would save tens of thousands of young lives at and still cost society less than child fever management in the baseline situation! It is not clear that scale-up via community health workers (CHWs) is to be preferred to a facility-based intervention. The delivery through CHWs allows for a broader coverage of using RDT and RRT, but with limited effectiveness due to limited skills of CHWs in treating and managing patients.