Africa's health: could the private sector accelerate the progress towards health MDGs?

BACKGROUND: Out of 1.484 billion disability-adjusted life years lost globally in 2008, 369.1 million (25%) were lost in the WHO African Region. Despite the heavy disease burden, the majority of countries in the Region are not on track to achieve Millennium Development Goals (MDG) 4 (reducing child mortality), 5 (improving maternal health), and 6 (combating HIV/AIDS, malaria and other diseases). This article provides an overview of the state of public health, summarizes 2010-2015 WHO priorities, and explores the role that private sector could play to accelerate efforts towards health MDGs in the African Region. DISCUSSION: Of the 752 total resolutions adopted by the WHO Regional Committee for Africa (RC) between years 1951 and 2010, 45 mention the role of the private sector. We argue that despite the rather limited role implied in RC resolutions, the private sector has a pivotal role in supporting the achievement of health MDGs, and articulating efforts with 2010-2015 priorities for WHO in the African Region: provision of normative and policy guidance as well as strengthening partnerships and harmonization; supporting the strengthening of health systems based on the Primary Health Care approach; putting the health of mothers and children first; accelerating actions on HIV/AIDS, malaria and tuberculosis; intensifying the prevention and control of communicable and noncommunicable diseases; and accelerating response to the determinants of health. CONCLUSION: The very high maternal and children mortality, very high burden of communicable and non-communicable diseases, health systems challenges, and inter-sectoral issues related to key determinants of health are too heavy for the public sector to address alone. Therefore, there is clear need for the private sector, given its breadth, scope and size, to play a more significant role in supporting governments, communities and partners to develop and implement national health policies and strategic plans; strengthen health systems capacities; and implement roadmaps for accelerating the attainment of health MDGs relating to maternal and child health, reducing disease burden, and promoting social determinants of health.In order for governments to further explore the potential benefits of the private sector towards improved performance of health systems, there is need for accurate evidence on the private sector capacity in areas of prevention, promotion, treatment and rehabilitation; dialogue and negotiation; clear definition of roles and responsibilities; and regulatory frameworks.

Technical efficiency of primary health units in Kailahun and Kenema districts of Sierra Leone.

BACKGROUND: The objectives of the study reported in this paper were to (i) estimate the technical efficiency of samples of community health centres (CHCs), community health posts (CHPs) and maternal and child health posts (MCHPs) in Kailahun and Kenema districts of Sierra Leone, (ii) estimate the output increases needed to make inefficient MCHPs, CHCs and CHPs efficient, and (iii) explore strategies for increasing technical efficiency of these institutions. METHODS: This study applies the data envelopment analysis (DEA) approach to analyse technical efficiency of random samples of 36 MCHPs, 22 CHCs and 21 CHPs using input and output data for 2008. RESULTS: The findings indicate that 77.8% of the MCHPs, 59.1% of the CHCs and 66.7% of the CHPs were variable returns to scale technically inefficient. The average variable returns to scale technical efficiency was 68.2% (SD = 27.2) among the MCHPs, 69.2% (SD = 33.2) among the CHCs and 59% (SD = 34.7) among the CHPs. CONCLUSION: This study reveals significant technical inefficiencies in the use of health system resources among peripheral health units in Kailahun and Kenema districts of Sierra Leone. There is need to strengthen national and district health information systems to routinely track the quantities and prices of resources injected into the health care systems and health service outcomes (indicators of coverage, quality and health status) to facilitate regular efficiency analyses.

Assessment of productivity of hospitals in Botswana: a DEA application.

BACKGROUND: Botswana national health policy states that the Ministry of Health shall from time to time review and revise its organization and management structures to respond to new developments and challenges in order to achieve and sustain a high level of efficiency in the provision of health care. Even though the government clearly views assuring efficiency in the health sector as one of its leadership and governance responsibilities, to date no study has been undertaken to measure the technical efficiency of hospitals which consume the majority of health sector resources. The specific objectives of this study were to quantify the technical and scale efficiency of hospitals in Botswana, and to evaluate changes in productivity over a three year period in order to analyze changes in efficiency and technology use. METHODS: DEAP software was used to analyze technical efficiency along with the DEA-based Malmquist productivity index which was applied to a sample of 21 non-teaching hospitals in the Republic of Botswana over a period of three years (2006 to 2008). RESULTS: The analysis revealed that 16 (76.2 percent), 16 (76.2 percent) and 13 (61.9 percent) of the 21 hospitals were run inefficiently in 2006, 2007 and 2008, with average variable returns to scale (VRS) technical efficiency scores of 70.4 percent, 74.2 percent and 76.3 percent respectively. On average, Malmquist Total Factor Productivity (MTFP) decreased by 1.5 percent. Whilst hospital efficiency increased by 3.1 percent, technical change (innovation) regressed by 4.5 percent. Efficiency change was thus attributed to an improvement in pure efficiency of 4.2 percent and a decline in scale efficiency of 1 percent. The MTFP change was the highest in 2008 (MTFP = 1.008) and the lowest in 2007 (MTFP = 0.963). CONCLUSIONS: The results indicate significant inefficiencies within the sample for the years under study. In 2008, taken together, the inefficient hospitals would have needed to increase the number of outpatient visits by 117627 (18 percent) and inpatient days by 49415 (13 percent) in order to reach full efficiency. Alternatively, inefficiencies could have been reduced by transferring 264 clinical staff and 39 beds to health clinics, health posts and mobile posts. The transfer of excess clinical staff to those facilities which are closest to the communities may also contribute to accelerating progress towards the Millennium Development Goals related to child and maternal health.Nine (57.1 percent) of the 21 hospitals experienced MTFP deterioration during the three years. We found the sources of inefficiencies to be either adverse change in pure efficiency, scale efficiency and/or technical efficiency.In line with the report Health financing: A strategy for the African Region, which was adopted by the Fifty-sixth WHO Regional Committee for Africa, it might be helpful for Botswana to consider institutionalizing efficiency monitoring of health facilities within health management information systems.

Economic burden of cholera in the WHO African region.

BACKGROUND: In 2007, various countries around the world notified 178677 cases of cholera and 4033 cholera deaths to the World Health Organization (WHO). About 62% of those cases and 56.7% of deaths were reported from the WHO African Region alone. To date, no study has been undertaken in the Region to estimate the economic burden of cholera for use in advocacy for its prevention and control. The objective of this study was to estimate the direct and indirect cost of cholera in the WHO African Region. METHODS: Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health-care system and the family in directly addressing cholera; and (b) the indirect costs, i.e. loss of productivity caused by cholera, which is borne by the individual, the family or the employer. The study was based on the number of cholera cases and deaths notified to the World Health Organization by countries of the WHO African Region. RESULTS: The 125018 cases of cholera notified to WHO by countries of the African Region in 2005 resulted in a real total economic loss of US$39 million, US$ 53.2 million and US$64.2 million, assuming a regional life expectancies of 40, 53 and 73 years respectively. The 203,564 cases of cholera notified in 2006 led to a total economic loss US$91.9 million, US$128.1 million and US$156 million, assuming life expectancies of 40, 53 and 73 years respectively. The 110,837 cases of cholera notified in 2007 resulted in an economic loss of US$43.3 million, US$60 million and US$72.7 million, assuming life expectancies of 40, 53 and 73 years respectively. CONCLUSION: There is an urgent need for further research to determine the national-level economic burden of cholera, disaggregated by different productive and social sectors and occupations of patients and relatives, and national-level costs and effectiveness of alternative ways of scaling up population coverage of potable water and clean sanitation facilities.

Economic burden of diabetes mellitus in the WHO African region.

BACKGROUND: In 2000, the prevalence of diabetes among the 46 countries of the WHO African Region was estimated at 7.02 million people. Evidence from North America, Europe, Asia, Latin America and the Caribbean indicates that diabetes exerts a heavy health and economic burden on society. Unfortunately, there is a dearth of such evidence in the WHO African Region. The objective of this study was to estimate the economic burden associated with diabetes mellitus in the countries in the African Region. METHODS: Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health systems and the families in directly addressing the problem; and (b) the indirect costs, i.e. the losses in productivity attributable to premature mortality, permanent disability and temporary disability caused by the disease. Prevalence estimates of diabetes for the year 2000 were used to calculate direct and indirect costs of diabetes mellitus. A discount rate of 3% was used to convert future earnings lost into their present values. The economic burden analysis was done for three groups of countries, i.e. 6 countries whose gross national income (GNI) per capita was greater than 8000 international dollars (i.e. in purchasing power parity), 6 countries with Int$2000-7999 and 33 countries with less than Int$2000. GNI for Zimbabwe was missing. RESULTS: The 7.02 million cases of diabetes recorded by countries of the African Region in 2000 resulted in a total economic loss of Int$25.51 billion (PPP). Approximately 43.65%, 10.03% and 46.32% of that loss was incurred by groups 1, 2 and 3 countries, respectively. This translated into grand total economic loss of Int$11,431.6, Int$4,770.6 and Int$ 2,144.3 per diabetes case per year in the three groups respectively. CONCLUSION: In spite of data limitations, the estimates reported here show that diabetes imposes a substantial economic burden on countries of the WHO African Region. That heavy burden underscores the urgent need for increased investments in the prevention and management of diabetes.

Efficient management of health centres human resources in Zambia.

This study uses Data Envelopment Analysis (DEA) to estimate the degree of technical, allocative and cost efficiency in individual public and private health centres in Zambia; and to identify the relative inefficiencies in the use of various inputs among individual health centers. About 83% of the 40 health centres were technically inefficient; and 88% of them were both allocatively and cost inefficient. The privately owned health centers were found to be more efficient than public facilities.

Determinants of health insurance ownership among South African women.

BACKGROUND: Studies conducted in developed countries using economic models show that individual- and household- level variables are important determinants of health insurance ownership. There is however a dearth of such studies in sub-Saharan Africa. The objective of this study was to examine the relationship between health insurance ownership and the demographic, economic and educational characteristics of South African women. METHODS: The analysis was based on data from a cross-sectional national household sample derived from the South African Health Inequalities Survey (SANHIS). The study subjects consisted of 3,489 women, aged between 16 and 64 years. It was a non-interventional, qualitative response econometric study. The outcome measure was the probability of a respondent's ownership of a health insurance policy. RESULTS: The chi2 test for goodness of fit indicated satisfactory prediction of the estimated logit model. The coefficients of the covariates for area of residence, income, education, environment rating, age, smoking and marital status were positive, and all statistically significant at p < or = 0.05. Women who had standard 10 education and above (secondary), high incomes and lived in affluent provinces and permanent accommodations, had a higher likelihood of being insured. CONCLUSION: Poverty reduction programmes aimed at increasing women's incomes in poor provinces; improving living environment (e.g. potable water supplies, sanitation, electricity and housing) for women in urban informal settlements; enhancing women's access to education; reducing unemployment among women; and increasing effective coverage of family planning services, will empower South African women to reach a higher standard of living and in doing so increase their economic access to health insurance policies and the associated health services.

Health economics: potential applications in HIV/AIDS control in Africa.

There is growing evidence that HIV/ AIDS has enormous negative impact on health status and economic development of individuals, households, communities and nations in the African region. Thus, there is urgent need for various disciplines to demonstrate how they can contribute in curbing the spread of this deadly disease in the African region. This paper, using an extended version of Professor Alan Williams schema as the conceptual framework, attempts to demonstrate how health economics can be used to inform policy and managerial choices related to HIV/AIDS advocacy, prevention, treatment and management. It argues that the discipline of health economics (and economics generally) is extremely valuable in: measuring health impacts of the disease and interventions; evaluating the relationships between health care-seeking behaviour of individuals and health system specific attributes; the estimation of determinants of compliance of HIV/AIDS patients with treatment regimen; establishing of health institutions efficiency in combating AIDS; guiding choices of HIV/AIDS interventions; assessing the relationships between HIV/AIDS, development, poverty, and trade; programme planning, monitoring and evaluation; and assessing health system's overall performance. The paper is a modest attempt to show how the discipline of health economics can elucidate, and help in resolving practical and conceptual issues in HIV/AIDS control in Africa.

Determinants of health insurance ownership among South African women

Background: Studies conducted in developed countries using economic models show that individual- and household- level variables are important determinants of health insurance ownership. There is however a dearth of such studies in sub-Saharan Africa. The objective of this study was to examine the relationship between health insurance ownership and the demographic, economic and educational characteristics of South African women. Methods: The analysis was based on data from a cross-sectional national household sample derived from the South African Health Inequalities Survey (SANHIS). The study subjects consisted of 3,489 women, aged between 16 and 64 years. It was a non-interventional, qualitative response econometric study. The outcome measure was the probability of a respondent's ownership of a health insurance policy. Results: The χ2 test for goodness of fit indicated satisfactory prediction of the estimated logit model. The coefficients of the covariates for area of residence, income, education, environment rating, age, smoking and marital status were positive, and all statistically significant at p ≤ 0.05. Women who had standard 10 education and above (secondary), high incomes and lived in affluent provinces and permanent accommodations, had a higher likelihood of being insured. Conclusion: Poverty reduction programmes aimed at increasing women's incomes in poor provinces; improving living environment (e.g. potable water supplies, sanitation, electricity and housing) for women in urban informal settlements; enhancing women's access to education; reducing unemployment among women; and increasing effective coverage of family planning services, will empower South African women to reach a higher standard of living and in doing so increase their economic access to health insurance policies and the associated health services

Using data envelopment analysis to measure the technical efficiency of public health centers in Kenya.

Data Envelopment Analysis has been widely used to analyze the efficiency of health sector in developed countries, since 1978, while in Africa, only a few studies have attempted to apply DEA in the health organizations. In this paper we measure technical efficiency of public health centers in Kenya. Our finding suggests that 44% of public health centers are inefficient. Therefore, the objectives of this study are: to determine the degree of technical efficiency of individual primary health care facilities in Kenya; to recommend the performance targets for inefficient facilities; to estimate the magnitudes of excess inputs; and to recommend what should be done with those excess inputs. The authors believe that this kind of studies should be undertaken in the other countries in the World Health Organization (WHO) African Region with a view to empowering Ministries of Health to play their stewardship role more effectively.

Impact of disaster-related mortality on gross domestic product in the WHO African Region.

BACKGROUND: Disaster-related mortality is a growing public health concern in the African Region. These deaths are hypothesized to have a significantly negative effect on per capita gross domestic product (GDP). The objective of this study was to estimate the loss in GDP attributable to natural and technological disaster-related mortality in the WHO African Region. METHODS: The impact of disaster-related mortality on GDP was estimated using double-log econometric model and cross-sectional data on various Member States in the WHO African Region. The analysis was based on 45 of the 46 countries in the Region. The data was obtained from various UNDP and World Bank publications. RESULTS: The coefficients for capital (K), educational enrolment (EN), life expectancy (LE) and exports (X) had a positive sign; while imports (M) and disaster mortality (DS) were found to impact negatively on GDP. The above-mentioned explanatory variables were found to have a statistically significant effect on GDP at 5% level in a t-distribution test. Disaster mortality of a single person was found to reduce GDP by US$0.01828. CONCLUSIONS: We have demonstrated that disaster-related mortality has a significant negative effect on GDP. Thus, as policy-makers strive to increase GDP through capital investment, export promotion and increased educational enrolment, they should always keep in mind that investments made in the strengthening of national capacity to mitigate the effects of national disasters expeditiously and effectively will yield significant economic returns.

Cost of mental and behavioural disorders in Kenya.

BACKGROUND: The health and economic impact of mental and behavioural disorders (MBD) is wide-ranging, long-lasting and large. Unfortunately, unlike in developed countries where studies on the economic burden of MBD exist, there is a dearth of such studies in the African Region of the World Health Organization. Yet, a great need for such information exists for use in sensitizing policy-makers in governments and civil society about the magnitude and complexity of the economic burden of MBD. The purpose of this study was to answer the following question: From the societal perspective (specifically the families and the Ministry of Health), what is the total cost of MBD patients admitted to various public hospitals in Kenya? METHODS: Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health care system and the family in directly addressing the problem of MBD; and (b) the indirect costs, i.e. loss of productivity caused by MBD, which is borne by the individual, the family or the employer. The study was based on Kenyan public hospitals, either dedicated to care of MBD patients or with a MBD ward. RESULTS: The study revealed that: (i) in the financial year 1998/99, the Kenyan economy lost approximately US$13,350,840 due to institutionalized MBD patients; (ii) the total economic cost of MBD per admission was US$2,351; (iii) the unit cost of operating and organizing psychiatric services per admission was US$1,848; (iv) the out-of-pocket expenses borne by patients and their families per admission was US$51; and (v) the productivity loss per admission was US$453. CONCLUSIONS: There is an urgent need for research in all African countries to determine: national-level epidemiological burden of MBD, measured in terms of the prevalence, incidence, mortality, and, probably, the disability-adjusted life-years lost; and the economic burden of MBD, broken down by different productive and social sectors and occupations of patients and relatives.

Measurement of technical efficiency of public hospitals in Kenya: using Data Envelopment Analysis.

In Sub-Saharan Africa (SSA), there is a huge knowledge gap of health facilities performance. The objective of this study is to measure relative technical efficiencies of 54 public hospitals in Kenya using Data Envelopment Analysis (DEA) technique. 14 (26%) of the public hospitals were found to be technically inefficient. The study singled out the inefficient hospitals and provided the magnitudes of specific input reductions or output increases needed to attain technical efficiency.

Impact of HIV/AIDS on Gross Domestic Product (GDP) in the WHO Africa Region.

HIV/AIDS is hypothesized to have substantive negative impact on health status and economic development of individuals, households, communities and nations. The objective of this study was to estimate the burden of HIV/AIDS on GDP in the WHO African Region using a production function approach. The economic burden analysis was done using a double-log econometric model and a cross-sectional data on 45 to 46 countries in the WHO African Region. The data were obtained from WHO, UNAIDS, ECA, UNDP and the World Bank publications. The coefficient for Capital (K), Education (EN), Export (X) and Imports (M) were found to be statistically significant determinants of per capita Gross Domestic Product (GDP) at 5% level of significance (using a one-sided t-distribution test). Unfortunately, HIV/AIDS morbidity (V) and HIV/AIDS deaths (VD), at the same level of significance, were found to have statistically insignificant impact on GDP. However, the coefficients of these variables had negative signs as expected. In all African countries, there is need for more detailed research on the total economic cost of HIV/AIDS (probably estimated using micro-level costing and willingness-to-pay methods) and for economic evaluations of treatment, prevention and promotion programmes.

Cost-effectiveness analysis of establishing a distance-education programme for health personnel in Swaziland.

There is a growing conviction among policy-makers that the availability of adequate numbers of well-trained and motivated human resources is a key determinant of health system' s capacity to achieve their health, responsiveness and fairness-improving goals. The objective of this study was to estimate the cost, effectiveness and incremental cost-effectiveness ratios of various distance-education strategies for the health sector in Swaziland; and recommend the most cost-effective option. The distance-education strategies evaluated included: Mobile library services (MLS); micro-resources centers WITHOUT video conferencing in five health centers and four regional hospitals (MRC-VC); micro-resources centers WITH video conferencing in five health centers and four regional hospitals (MRC+VC); centralized resource center WITHOUT video conferencing (CRC-VC); centralized resource center WITH video conferencing (CRC+VC); and status quo (SQ). The incremental cost-effectiveness ratio for MLS was Emalangeni (E) 41,846; MRC-VC was E42,696; MRC+VC was E45,569; CRC-VC was E43,578; CRC+VC was E40,827; the latter being the most cost-effective distance-education strategy. According to policy-makers, this study served to clarify the various distance-education strategies, their costs and their benefits/effectiveness. There is a need for developing in Africa a culture of basing policy and management decisions of such kind on systematic analyses. Of course, economic evaluation will, at most, be a guide to policy- and decision-making, and thus, the onus of decision-making will always be on policy-makers and health-care managers.

The burden of natural and technological disaster-related mortality on gross domestic product (GDP) in the WHO African region.

The WHO Africa region has the highest disaster mortality rate compared to the other five regions of the organization. Those deaths are hypothesized to have significantly negative effect on per capita gross domestic product (GDP). The objective of this study was to estimate the loss in GDP attributable to natural and technological disaster-related mortality in the WHO African Region. We estimated the impact of disaster-related mortality on GDP using double-log econometric model and cross-sectional data (from the UNDP and the World Bank publications) on 45 out of 46 countries in the WHO African Region. The coefficients for capital (K), educational enrolment (EN), life expectancy (LE) and exports (X) had a positive sign; while imports (M) and disaster mortality (DS) were found to impact negatively on GDP. The abovementioned explanatory variables were found to have statistically significant effect on GDP at 5% level in a t-distribution test. Disaster mortality of a single person was found to reduce GDP by US$0.018. We have demonstrated that disaster mortality has a significant negative effect on GDP. Thus, as policy-makers strive to increase GDP through capital investment, export promotion and increase in educational enrolment, they should always recall that investments in strengthening national capacity to mitigate the effects of national disasters expeditiously and effectively shall yield significant economic returns.