Unaffordability of COVID-19 tests: assessing age-related inequalities in 83 countries.

BACKGROUND: Diagnostic testing for SARS-CoV-2 is critical to manage the pandemic and its different waves. The requirement to pay out-of-pocket (OOP) for testing potentially represents both a financial barrier to access and, for those who manage to make the payment, a source of financial hardship, as they may be forced to reduce spending on other necessities. This study aims to assess age-related inequality in affordability of COVID-19 tests. METHODS: Daily data from the Global COVID-19 Trends and Impact Survey among adult respondents across 83 countries from July 2020 to April 2021 was used to monitor age-related inequalities across three indicators: the experiences of, first, reducing spending on necessities because of paying OOP for testing, second, facing financial barriers to get tested (from January to April 2021), and third, having anxiety related to household finance in the future. Logistic regressions were used to assess the association of age with each of these. RESULTS: Among the population ever tested, the adjusted odds of reducing spending on necessities due to the cost of the test decreased non-linearly with age from 2.3 [CI95%: 2.1-2.5] among ages 18-24 to 1.6 [CI95%: 1.5-1.8] among ages 45-54. Among the population never tested, odds of facing any type of barrier to testing were highest among the youngest age group 2.5 [CI95%:2.4-2.5] and decreased with age. Finally, among those reporting reducing spending on necessities, the odds of reporting anxiety about their future finances decreased non-linearly with age, with the two younger groups being 2.4-2.5 times more anxious than the oldest age group. Among those reporting financial barriers due to COVID-19 test cost, there was an inverse U-shape relationship. CONCLUSIONS: COVID-19 testing was associated with a reduction in spending on necessities at varying levels by age. Younger people were more likely to face financial barrier to get tested. Both negative outcomes generated anxiety across all age-groups but more frequently among the younger ones. To reduce age-related inequalities in the affordability of COVID-19 test, these findings support calls for exempting everyone from paying OOP for testing and, removing other type of barriers than financial ones.

Public Financial Management as an Enabler for Health Financing Reform: Evidence from Free Health Care Policies Implemented in Burkina Faso, Burundi, and Niger.

In Burkina Faso, Burundi and Niger, the policy to remove user fees for primary care was carried out through significant adjustments in public financial management (PFM). The paper analyzes the PFM adjustments by stage of the budget cycle and describes their importance for health financing. The three countries shifted from input-based to program-based allocation for primary care facility compensation, allowed service providers autonomy to access and manage the funds, and established budget performance monitoring frameworks related to outputs. These PFM changes, in turn, enabled key improvements in health financing, namely, more direct funding of primary care facilities from general budget revenue, and payments to those service providers based on outputs and drawn from noncontributory entitlements. The paper draws on these experiences to provide key lessons on the PFM enabling conditions needed to expand health coverage through public financing mechanisms.

Impact of the extension of a performance-based financing scheme to nutrition services in Burundi on malnutrition prevention and management among children below five: A cluster-randomized control trial.

Malnutrition is a huge problem in Burundi. In order to improve the health system response, the Ministry of Health piloted the introduction of malnutrition prevention and care indicators within its performance-based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services. The objective of this study is to assess the impacts of this intervention, on both child acute malnutrition recovery rates at health centre level and prevalence of chronic and acute malnutrition among children at community level. This study follows a cluster-randomized controlled evaluation design: 90 health centres (HC) were randomly selected for the study, 45 of them were randomly assigned to the intervention and received payment related to their performance in malnutrition activities, while the other 45 constituted the control group and got a simple budget allocation. Data were collected from baseline and follow-up surveys of the 90 health centres and 6,480 households with children aged 6 to 23 months. From the respectively 1,067 and 1,402 moderate and severe acute malnutrition transcribed files and registers, findings suggest that the intervention had a positive impact on moderate acute malnutrition recovery rates (OR: 5.59, p = 0.039 -at the endline, 78% in the control group and 97% in the intervention group) but not on uncomplicated severe acute malnutrition recovery rate (OR: 1.16, p = 0.751 -at the endline, 93% in the control group and 92% in the intervention group). The intervention also had a significant increasing impact on the number of children treated for acute malnutrition. Analyses from the anthropometric data collected among 12,679 children aged 6-23 months suggest improvements at health centre level did not translate into better results at community level: prevalence of both acute and chronic malnutrition remained high, precisely at the endline, acute and chronic malnutrition prevalence were resp. 8.80% and 49.90% in the control group and 8.70% and 52.0% in the intervention group, the differences being non-significant. PBF can contribute to a better management of malnutrition at HC level; yet, to address the huge problem of child malnutrition in Burundi, additional strategies are urgently required.

Effects in spite of tough constraints - A theory of change based investigation of contextual and implementation factors affecting the results of a performance based financing scheme extended to malnutrition in Burundi.

BACKGROUND: From January 2015 to December 2016, the health authorities in Burundi piloted the inclusion of child nutrition services into the pre-existing performance-based financing free health care policy (PBF-FHC). An impact evaluation, focused on health centres, found positive effects both in terms of volume of services and quality of care. To some extent, this result is puzzling given the harshness of the contextual constraints related to the fragile setting. METHODS: With a multi-methods approach, we explored how contextual and implementation constraints interacted with the pre-identified tracks of effect transmission embodied in the intervention. For our analysis, we used a hypothetical Theory of Change (ToC) that mapped a set of seven tracks through which the intervention might develop positive effects for children suffering from malnutrition. We built our analysis on (1) findings from the facility surveys and (2) extra qualitative data (logbooks, interviews and operational document reviews). FINDINGS: Our results suggest that six constraints have weighted upon the intervention: (1) initial low skills of health workers; (2) unavailability of resources (including nutritional dietary inputs and equipment); (3) payment delays; (4) suboptimal information; (5) restrictions on autonomy; and (6) low intensity of supervision. Together, they have affected the intensity of the intervention, especially during its first year. From our analysis of the ToC, we noted that the positive effects largely occurred as a result of the incentive and information tracks. Qualitative data suggests that health centres have circumvented the many constraints by relying on a community-based recruitment strategy and a better management of inputs at the level of the facility and the patient himself. CONCLUSION: Frontline actors have agency: when incentives are right, they take the initiative and find solutions. However, they cannot perform miracles: Burundi needs a holistic societal strategy to resolve the structural problem of child malnutrition. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).

The impact of reimbursed user fee exemption of health centre outpatient consultations for the poor in pluralistic health systems: lessons from a quasi-experiment in two rural health districts in Cambodia.

Fees charged at the point of use are a barrier to the health services' users, especially for the poorest. Two decades ago, Cambodia introduced the so-called health equity fund (HEF) strategy, a waiver scheme which enhances access to public health services for the poor without undermining the economic situation of facilities. Evidence suggests that hospital-based HEF effectively removed financial barriers and reduced out-of-pocket expenditures. There is less evidence on the effectiveness of the HEF when assistance is extended to the primary level of healthcare. This research explores the impact of a HEF extended to health centres in two rural health districts. Two household surveys and 16-month diary data allowed to assess the impact of the intervention on health-seeking behaviours and expenditure of poor households. Though HEF effectively removed user fees at public health facilities, health centre utilization of sick and poor people did not budge much in the intervention district; self-medication and private provider consultations remained the preferred health-seeking behaviours, by far, even if more expensive. Difference-in-difference estimates confirmed that HEF had a slight impact on health-seeking behaviours, but only for the subgroups of HEF beneficiaries living close to the health centre and ready to test their new entitlement. This research reminds on the importance of the context for the effectiveness of any policy: in a highly pluralistic health sector, waiving already low-user fees in public health centres may be insufficient to increase rapidly the use of those facilities and reduce catastrophic spending. In such context, apart from distance to health centres, perceived quality of services at the health centres, which was relatively low compared with other providers, also matters. Although the HEF scheme plays a role in improving perceived and objective quality of care, complementary means are to be deployed.

Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi?

BACKGROUND: The Integrated Management of Childhood Illness (IMCI) strategy was adopted in Burundi in 2003. Our aim was to evaluate to what extent the malnutrition component of the IMCI guidelines is implemented at health facilities level. METHODS: We carried out direct observations of curative outpatient consultations for children aged 6-59 months in 90 health centres selected randomly. We considered both the child and the health worker (HW) as units of analysis and used bivariate analysis to explore characteristics of HWs associated with tasks systematically or never performed. RESULTS: A total of 514 consultations carried out by 145 HWs were observed. Among the 250 children under two years, less than 30% were asked questions on breastfeeding. None of them had all seven nutrition-related questions asked to their caregivers and none of the 200 children over the age of two years had all five nutrition-related questions asked to their caregivers. Only 13 cases (3%) had all of the six examinations/tasks (weight, height/length, mid-upper arm circumference, oedema, filling in and discussing the growth curve and calculating the weight for height z-score) performed as part of their care. 393 cases (76%) reported that they had not being given any nutrition advice.With regards to HWs, among 99 of them who had received children under two, only 21 (21.2%)[14.2-30.5%) systematically asked the question regarding 'ongoing breastfeeding'.Only 56 (38.6%)[31-46.9%] weighed or discussed the weight taken prior the consultation for each child they reviewed, only 38 (26.2%)[19.6-34.1%] measured the height/length or discussed it for each child reviewed and 23 (15.9%)[10.7-22.8%] performed (systematically?) the WHZ-score.More than 50% never gave nutrition advices to any child reviewed.HWs who daily manage severe acute malnutrition were the most likely to systematically ask the question regarding 'ongoing breastfeeding' and to perform a 'weight examination'. Those who had not received supervision visit on the topic of malnutrition predominantly never performed a 'weight examination'. The 'height/length' examination' was predominantly performed by female HWs and those who have 'contract with the government. CONCLUSION: This study has found poor compliance by HWs to IMCI in Burundi. This indicates that a substantial proportion of children do not receive early and appropriate care, especially that pertaining to malnutrition. This alarming situation calls for strong action by actors committed to child health in the country. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).

Contribution of the results-based financing strategy to improving maternal and child health indicators in Burkina Faso.

In response to the poor performance of its public health care provision, Burkina Faso decided, to implement results-based financing (RBF). This strategy relies on a strategic purchase of the quantity and quality of services provided by health workers, monitored by a set of indicators. However, there is a lack of evidence on its effects. The objective of this article is to appreciate the effect of RBF on a set of maternal and child health (MCH) indicators in Burkina Faso. The study design is quasi-experimental comparative with a control group before and after the implementation of the RBF. To estimate the effect of RBF, we used two methods of analysis: (1) the segmented regression to measure the effect of RBF in the health districts (HD) implementing RBF (RBF HD) and (2) the difference-in-difference test to estimate the effect of RBF considering the differences in mean between RBF HD and HD that did not implement RBF (non-RBF HD). We found among five indicators studied that only the postnatal consultation coverage in RBF HD was significantly higher (7.68%; P = 0.04) than in the non-RBF HD. Overall, our findings do not clearly demonstrate the effectiveness of RBF in improving MCH indicators in Burkina Faso.

The effect of text message support on diabetes self-management in developing countries - A randomised trial.

OBJECTIVE: mHealth interventions have the potential to facilitate self-management. This TEXT4DSM study implemented a mobile phone intervention in existing diabetes programmes in three low- and middle-income countries (Democratic Republic of Congo, Cambodia, and the Philippines). RESEARCH DESIGN AND METHODS: Sub-studies with a similar randomised controlled trial design were conducted in three different countries. Each sub-study included 480 adults with diabetes. Subjects were randomised to receive either routine care or routine care plus text message self-management support. The primary outcome was the difference in the proportion of subjects with well-controlled diabetes after 2 years. RESULTS: Baseline and 2-year HbA1c measurements were available for 781 individuals. After 2 years, the proportion of subjects with controlled HbA1c was 2.8% higher in the intervention group than in the control group (difference not statistically significant). In the logistic regression model, the odds ratio for having controlled diabetes after the intervention was 1.1, after adjusting for baseline HbA1c level, sex, receiving insulin treatment, and participating in the routine programme. The HbA1c dynamics over time differed between programmes; the number of people with controlled diabetes tended to increase in DR Congo and decrease in Cambodia. CONCLUSION: This study was the first to test the same mHealth intervention in different countries. The finding that text messages did not show an additional effect on diabetes control implied that expectations about mHealth should be cautious. The degree of coverage, the quality of the routine programme, and the progression of disease can interfere with the expected impact. Trial registration: ISRCTN registry (86247213).

Determinants of stunting and severe stunting among Burundian children aged 6-23 months: evidence from a national cross-sectional household survey, 2014.

BACKGROUND: Burundi is one of the poorest countries and is among the four countries with the highest prevalence of stunting (58%) among children aged less than 5 years. This situation undermines the economic growth of the country as undernutrition is strongly associated with less schooling and reduced economic productivity. Identifying the determinants of stunting and severe stunting may help policy-makers to direct the limited Burundian resources to the most vulnerable segments of the population, and thus make it more cost effective. This study aimed to identify predictors of stunting and severe stunting among children aged less than two years in Burundi. METHODS: The sample is made up of 6199 children aged 6 to 23 months with complete anthropometric measurements from the baseline survey of an impact evaluation study of the Performance-Based financing (PBF) scheme applied to nutrition services in Burundi from 2015 to 2017. Binary and multivariable logistic regression analyses were used to examine stunting and severe stunting against a set of child, parental and household variables such as child's age or breastfeeding pattern, mother's age or knowledge of malnutrition, household size or socio-economic status. RESULTS: The prevalence of stunting and severe stunting were 53% [95%CI: 51.8-54.3] and 20.9% [95%CI: 19.9-22.0] respectively. Compared to children from 6-11 months, children of 12-17 months and 18-23 months had a higher risk of stunting (AdjOR:2.1; 95% CI: 1.8-2.4 and 3.2; 95% CI: 2.8-3.7). Other predictors for stunting were small babies (AdjOR=1.5; 95% CI: 1.3-1.7 for medium-size babies at birth and AdjOR=2.9; 95% CI: 2.4-3.6 for small-size babies at birth) and male children (AdjOR=1.5, 95% CI: 1.4-1.8). In addition, having no education for mothers (AdjOR=1.6; 95% CI: 1.2-2.1), incorrect mothers' child nutrition status assessment (AdjOR=3.3; 95% CI: 2.8-4), delivering at home (AdjOR=1.4; 95% CI: 1.2-1.6) were found to be predictors for stunting. More than to 2 under five children in the household (AdjOR=1.45; 95% CI: 1.1-1.9 for stunting and AdjOR= 1.5; 95% CI: 1.2-1.9 for severe stunting) and wealth were found to be predictors for both stunting and severe stunting. The factors associated with stunting were found to be applicable for severe stunting as well. CONCLUSION: Mother's education level, mother's knowledge about child nutrition status assessment and health facility delivery were predictors of child stunting. Our study confirms that stunting and severe stunting is in Burundi, as elsewhere, a multi-sectorial problem. Some determinants relate to the general development of Burundi: education of girls, poverty, and food security; will be addressed by a large array of actions. Some others relate to the health sector and its performance - we think in particular of the number of children under five in the household (birth spacing), the relationship with the health center and the knowledge of the mother on malnutrition. Our findings confirm that the Ministry of Health and its partners should strive for better performing and holistic nutrition services: they can contribute to better nutrition outcomes.

How User Fees Influence Contraception in Low and Middle Income Countries: A Systematic Review.

Accessible and quality reproductive health services are critical for low- and middle-income countries (LMICs). After a decade of waning investment in family planning, interest and funding are growing once again. This article assesses whether introducing, removing, or changing user fees for contraception has an effect on contraceptive use. We conducted a search of 14 international databases. We included randomized controlled trials, interrupted-time series analyses, controlled before-and-after study designs, and cohort studies that reported contraception-related variables as an outcome and a change in the price of contraceptives as an intervention. Four studies were eligible but none was at low risk of bias overall. Most of these, as well as other studies not included in the present research, found that demand for contraception was not cost-sensitive. We could draw no robust summary of evidence, strongly suggesting that further research in this area is needed.

Measuring and understanding the effects of a performance based financing scheme applied to nutrition services in Burundi-a mixed method impact evaluation design.

BACKGROUND: Malnutrition is a huge problem in Burundi. In order to improve the provision of services at hospital, health centre and community levels, the Ministry of Health is piloting the introduction of malnutrition prevention and care indicators within its performance based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services, as PBF has done, in Burundi and elsewhere, for several other services. METHODS: This paper presents the protocol for the impact evaluation of the PBF scheme applied to malnutrition. The research design consists in a mixed methods model adopting a sequential explanatory design. The quantitative component is a cluster-randomized controlled evaluation design: among the 90 health centres selected for the study, half receive payment related to their results in malnutrition activities, while the other half get a budget allocation. Qualitative research will be carried out both during the intervention period and at the end of the quantitative evaluation. Data are collected from 1) baseline and follow-up surveys of 90 health centres and 6,480 households with children aged 6 to 23 months, 2) logbooks filled in weekly in health centres, and 3) in-depth interviews and focus group discussions. The evaluation aims to provide the best estimate of the impact of the project on malnutrition outcomes in the community as well as outputs at the health centre level (malnutrition care outputs) and to describe quantitatively and qualitatively the changes that took place (or did not take place) within health centres as a result of the program. DISCUSSION: Although PBF schemes are blooming in low in-come countries, there is still a need for evidence, especially on the impact of revising the list of remunerated indicators. It is expected that this impact evaluation will be helpful for the national policy dialogue in Burundi, but it will also provide key evidence for countries with an existing PBF scheme and confronted with malnutrition problems on the appropriateness to extend the strategy to nutrition services. TRIAL REGISTRATION: ClinicalTrials.gov PRS Identifier: NCT02721160; registered March 2016.

Boosting facility deliveries with results-based financing: a mixed-methods evaluation of the government midwifery incentive scheme in Cambodia.

BACKGROUND: Increasing the coverage of skilled attendance at births in a health facility (facility delivery) is crucial for saving the lives of mothers and achieving Millennium Development Goal five. Cambodia has significantly increased the coverage of facility deliveries and reduced the maternal mortality ratio in the last decade. The introduction of a nationwide government implemented and funded results-based financing initiative, known as the Government Midwifery Incentive Scheme (GMIS), is considered one of the most important contributors to this. We evaluated GMIS to explore its effects on facility deliveries and the health system. METHODS: We used a mixed-methods design. An interrupted time series model was applied, using routine longitudinal data on reported deliveries between 2006 and 2011 that were extracted from the health information system. In addition, we interviewed 56 key informants and performed 12 focus group discussions with 124 women who had given birth (once or more) since 2006. Findings from the quantitative data were carefully interpreted and triangulated with those from qualitative data. RESULTS: We found that facility deliveries have tripled from 19% of the estimated number of births in 2006 to 57% in 2011 and this increase was more substantial at health centres as compared to hospitals. Segmented linear regressions showed that the introduction of GMIS in October 2007 made the increase in facility deliveries and deliveries with skilled attendants significantly jump by 18 and 10% respectively. Results from qualitative data also suggest that the introduction of GMIS together with other interventions that aimed to improve access to essential maternal health services led to considerable improvements in public health facilities and a steep increase in facility deliveries. Home deliveries attended by traditional birth attendants decreased concomitantly. We also outline several operational issues and limitations of GMIS. CONCLUSIONS: The available evidence strongly suggests that GMIS is an effective mechanism to complement other interventions to improve health system performance and boost facility deliveries as well as skilled birth attendance; thereby contributing to the reduction of maternal mortality. Our findings provide useful lessons for Cambodia to further improve GMIS and for other low-income countries to implement similar results-based financing mechanisms.