Leaving no one behind in armed conflict-affected settings of Africa: is universal health coverage a possibility or mirage?

The world is off track six years to the 2030 deadline for attaining the sustainable development goals and universal health coverage. This is particularly evident in Africa's armed conflict-affected and humanitarian settings, where pervasively weak health systems, extreme poverty and inequitable access to the social dimensions and other determinants of health continue to pose significant challenges to universal health coverage. In this article, we review the key issues and main barriers to universal health coverage in such settings. While our review shows that the current health service delivery and financing models in Africa's armed conflict-affected settings provide some opportunities to leapfrog progress, others are threats which could hinder the attainment of universal health coverage. We propose four key approaches focused on addressing the barriers to the three pillars of universal health coverage, strengthening public disaster risk management, bridging the humanitarian-development divide, and using health as an enabler of peace and sustainable development as panacea to addressing the universal health coverage challenge in these settings. The principles of health system strengthening, primary health care, equity, the right to health, and gender mainstreaming should underscore the implementation of these approaches. Moving forward, we call for more advocacy, dialogue, and research to better define and adapt these approaches into a realistic package of interventions for attaining universal health coverage in Africa's armed conflict-affected settings.

COVID-19 Vaccination in the WHO African Region: Progress Made in 2022 and Factors Associated.

This study summarizes progress made in rolling out COVID-19 vaccinations in the African region in 2022, and analyzes factors associated with vaccination coverage. Data on vaccine uptake reported to the World Health Organization (WHO) Regional Office for Africa by Member States between January 2021 and December 2022, as well as publicly available health and socio-economic data, were used. A negative binomial regression was performed to analyze factors associated with vaccination coverage in 2022. As of the end of 2022, 308.1 million people had completed the primary vaccination series, representing 26.4% of the region's population, compared to 6.3% at the end of 2021. The percentage of health workers with complete primary series was 40.9%. Having carried out at least one high volume mass vaccination campaign in 2022 was associated with high vaccination coverage (ß = 0.91, p < 0.0001), while higher WHO funding spent per person vaccinated in 2022 was correlated with lower vaccination coverage (ß = -0.26, p < 0.03). All countries should expand efforts to integrate COVID-19 vaccinations into routine immunization and primary health care, and increase investment in vaccine demand generation during the transition period that follows the acute phase of the pandemic.

Improving access to affordable vaccines for middle-income countries in the african region.

Despite the remarkable power of immunization reducing morbidity and mortality due to vaccine preventable diseases, one in five African children still does not receive all the basic, necessary vaccines. This is particularly true of the 10 middle-income countries (MICs) in the WHO African Region, where data demonstrates that immunization coverage is decreasing. These countries are not eligible for Gavi support in accessing new vaccines because of their relatively high per capita income level and will gradually increase with the transitioning of countries out of Gavi support. Thus, WHO was requested to facilitate access to affordable vaccines in relation to middle-income countries and those transitioning out of Gavi support in the near future. With commitment to address the issue, WHO Regional Office for Africa convened a consultative meeting from 09 to 11 April 2018 in Brazzaville, Congo to explore ways of improving access to affordable vaccines for MICs in the Region. The meeting brought together 17 low, middle and upper middle income countries in the African Region. Immunization partners and other WHO Regions also participated in the consultation to share experiences and explore ways of increasing access to affordable vaccines in MICs in the African Region. At the end of the meeting a number of solutions and action points were proposed for implementation in the Region.

Cost of a human papillomavirus vaccination project, Zimbabwe.

OBJECTIVE: To determine the cost of Zimbabwe's human papillomavirus (HPV) vaccination demonstration project. METHODS: The government of Zimbabwe conducted the project from 2014-2015, delivering two doses of HPV vaccine to 10-year-old girls in two districts. School delivery was the primary vaccination strategy, with health facilities and outreach as secondary strategies. A retrospective cost analysis was conducted from the provider perspective. Financial costs (government expenditure) and economic costs (financial plus the value of existing or donated resources including vaccines) were calculated by activity, per dose and per fully immunized girl. RESULTS: The project delivered 11 599 vaccine doses, resulting in 5724 fully immunized girls (5540 at schools, 168 at health facilities and 16 at outreach points). The financial cost for service delivery per fully immunized girl was United States dollars (US$) 5.34 in schools, US$ 34.90 at health facilities and US$ 288.63 at outreach; the economic costs were US$ 17.39, US$ 41.25 and US$ 635.84, respectively. The mean financial cost per dose was US$ 19.76 and per fully immunized girl was US$ 40.03 (economic costs were US$ 45.00 and US$ 91.19, respectively). The largest number of doses delivered (5788) occurred during the second vaccination round (the second group's first dose concurrently delivered with the first group's second dose), resulting in the lowest financial and economic service delivery costs per dose: US$ 1.97 and US$ 6.79, respectively. CONCLUSION: The mean service delivery cost was lower in schools (primary strategy) and when more girls were vaccinated in each round, demonstrating scale efficiency.

Towards Immunization Financing Sustainability in Africa.

Immunization programme has contributed to saving many lives from avoidable deaths and bring many other benefits, including healthier children, increased school attendance, and increased productivity. In the past 10 years, immunization as a public health intervention has expanded in target as well as number of vaccines to be delivered to a broader range of people and new vaccines. Immunization is also exceptionally of good value, returning many dollars in economic benefits for every dollar invested in immunization services. Healthy individuals are more productive, earn more, save more, invest more, consume more, and work longer: which all impact to increase a nation's GDP. Immunization is one of the most effective, and cost-effective, public health tools that contribute to this situation. Fully immunized children have better educational outcomes and, over time, make for a more productive workforce. Consequently immunization, which must be sustained indefinitely, as a long-term investment require stable, long-term financing. A start point is a plan which is translated into funding for the programme. In sustainability a detailed planning process that assures a review of the situation leading to detailed programming in terms of response to challenges and finally culminating in costing so that funding requirements are determined and mobilised cannot be overemphasized. The experience has been varied in Africa region. While governments have made significant strides to increase funding for immunization programs over the last five years, further commitment is needed to achieve full financing and national ownership of immunization programs. Most countries have adopted the Comprehensive Multi-year Planning framework for planning and are thus able to put together their resource needs for immunization programmes. To continue to have the necessary benefits of high coverage and cover the increased investment requirements governments will need to do more to assure robust funding in a sustainable and predictable manner. The paper tells the story of importance of planning using the cMYP processes to immunization financing sustainability as a necessary condition in the trajectory towards sustainability. This article presents the experience of countries from planning to funding, drawing on the interconnectedness of adequate planning, ability to mobilise resources and thus better move towards sustainable funding. As governments pursue high level order of planning, they are in a better position to stem overdependence on Gavi and other external support for future sustainability.

South-South cooperation as a mechanism to strengthen public health services in Africa: experiences, challenges and a call for concerted action.

Implementation of new models of development cooperation have been on the increase lately. Coupled with this are calls for use of horizontal development cooperation mechanisms such as South-South Cooperation (SSC) as a way to enhance aid effectiveness in the health sector of developing countries. In this case series, we review recent experiences in the application of SSC initiatives to two public health situations in Africa to demonstrate the veracity of this new paradigm. Our review highlight the immense benefits associated with the use of SSC for health and provide evidence for increasing use of horizontal development coordination mechanisms to strengthen public health services delivery and socioeconomic development among African countries. Opportunities for SSC among African countries include in the areas of disease prevention and control, production of medical products and essential medicines, harmonization of regulatory processes, and health workforce development among others. However, pitfalls such as poor coordination, inadequate political commitment, lack of conducive policy environments, language barrier and inadequate financing opportunities for SSC initiatives present major dilemma for the use of SSC mechanisms. We conclude that the need for a paradigm shift from vertical to horizontal development cooperation needs no further proof but a call to action. We call on the concerned stakeholders to support the establishment of a systematic approach for use of SSC mechanisms in the health sector of Africa, designation of an African Centre of Excellence for SSC in public health and development of a regional mechanism for monitoring and evaluation of SSC initiatives in Africa.

Cost of a human papillomavirus vaccination project, Zimbabwe

Objective To determine the cost of Zimbabwe's human papillomavirus (HPV) vaccination demonstration project. Methods The government of Zimbabwe conducted the project from 2014­2015, delivering two doses of HPV vaccine to 10-year-old girls in two districts. School delivery was the primary vaccination strategy, with health facilities and outreach as secondary strategies. A retrospective cost analysis was conducted from the provider perspective. Financial costs (government expenditure) and economic costs (financial plus the value of existing or donated resources including vaccines) were calculated by activity, per dose and per fully immunized girl. Results The project delivered 11 599 vaccine doses, resulting in 5724 fully immunized girls (5540 at schools, 168 at health facilities and 16 at outreach points). The financial cost for service delivery per fully immunized girl was United States dollars (US$) 5.34 in schools, US$ 34.90 at health facilities and US$ 288.63 at outreach; the economic costs were US$ 17.39, US$ 41.25 and US$ 635.84, respectively. The mean financial cost per dose was US$ 19.76 and per fully immunized girl was US$ 40.03 (economic costs were US$ 45.00 and US$ 91.19, respectively).The largest number of doses delivered (5788) occurred during the second vaccination round (the second group's first dose concurrently delivered with the first group's second dose), resulting in the lowest financial and economic service delivery costs per dose: US$ 1.97 and US$ 6.79, respectively. Conclusion The mean service delivery cost was lower in schools (primary strategy) and when more girls were vaccinated in each round, demonstrating scale efficiency

Evaluation of economic costs of a measles outbreak and outbreak response activities in Keffa Zone, Ethiopia.

OBJECTIVE: To estimate the economic impact of a measles outbreak and response activities that occurred in Keffa Zone, Ethiopia with 5257 reported cases during October 1, 2011-April 8, 2012, using the health sector and household perspectives. METHODS: We collected cost input data through interviews and record reviews with government and partner agency staff and through a survey of 100 measles cases-patients and their caretakers. We used cost input data to estimate the financial and opportunity costs of the following outbreak and response activities: investigation, treatment, case management, active surveillance, immunization campaigns, and immunization system strengthening. FINDINGS: The economic cost of the outbreak and response was 758,869 United States dollars (US$), including the opportunity cost of US$327,545 (US$62.31/case) and financial cost of US$431,324 (US$82.05/case). Health sector costs, including the immunization campaign (US$72.29/case), accounted for 80% of the economic cost. Household economic cost was US$29.18/case, equal to 6% of the household median annual income. 92% of financial costs were covered by partner agencies. CONCLUSION: The economic cost of the measles outbreak was substantial when compared to household income and health sector expenditures. Improvement in two-dose measles vaccination coverage above 95% would both reduce measles incidence and save considerable outbreak-associated costs to both the health sector and households.

Preferences for benefit packages for community-based health insurance: an exploratory study in Nigeria.

BACKGROUND: It is important that community-based health insurance (CBHI) schemes are designed in such a way as to ensure the relevance of the benefit packages to potential clients. Hence, this paper provides an understanding of the preferred benefit packages by different economic status groups as well as urban and rural dwellers for CBHI in Southeast Nigeria. METHODS: The study took place in rural, urban and semi-urban communities of south-east Nigeria. A questionnaire was used to collect information from 3070 randomly picked household heads. Focus group discussions were used to collect qualitative data. Data was examined for links between preferences for benefit packages with SES and geographic residence of the respondents. RESULTS: Respondents in the rural areas and in the lower SES preferred a comprehensive benefit package which includes all inpatient, outpatient and emergencies services, while those in urban areas as well as those in the higher SES group showed a preference for benefit packages which will cover only basic disease control interventions. CONCLUSION: Equity concerns in preferences for services to be offered by the CBHI scheme should be addressed for CBHI to succeed in different contexts.

Willingness to pay for community-based health insurance in Nigeria: do economic status and place of residence matter?

OBJECTIVE: We examine socio-economic status (SES) and geographic differences in willingness of respondents to pay for community-based health insurance (CBHI). METHODS: The study took place in Anambra and Enugu states, south-east Nigeria. It involved a rural, an urban and a semi-urban community in each of the two states. A pre-tested interviewer-administered questionnaire was used to collect information from a total of 3070 households selected by simple random sampling. Contingent valuation was used to elicit willingness to pay (WTP) using the bidding game format. Data were examined for correlation between SES and geographic locations with WTP. Log ordinary least squares (OLS) was used to examine the construct validity of elicited WTP. RESULTS: Generally, less than 40% of the respondents were willing to pay for CBHI membership for themselves or other household members. The proportions of people who were willing to pay were much lower in the rural communities, at less than 7%. The average that respondents were willing to pay as a monthly premium for themselves ranged from 250 Naira (US$1.7) in a rural community to 343 Naira (US$2.9) in an urban community. The higher the SES group, the higher the stated WTP amount. Similarly, the urbanites stated higher WTP compared with peri-urban and rural dwellers. Males and people with more education stated higher WTP values than females and those with less education. Log OLS also showed that previously paying out-of-pocket for health care was negatively related to WTP. Previously paying for health care using any health insurance mechanism was positively related to WTP. CONCLUSION: Economic status and place of residence amongst other factors matter in peoples' WTP for CBHI membership. Consumer awareness has to be created about the benefits of CBHI, especially in rural areas, and the amount to be paid has to be augmented with other means of financing (e.g. government and/or donor subsidies) to ensure success and sustainability of CBHI schemes.

Quantifying the economic burden of malaria in Nigeria using the willingness to pay approach.

BACKGROUND: Malaria illness imposes great burden on the society as it has adverse effects on the physical, mental and social well being of the people as well as on the economic development of the nation. METHODS: The study uses the Willingness To Pay (WTP) approach to evaluate the burden of malaria in Nigeria. RESULTS: The results indicate that households would be prepared to pay an average of about Naira 1,112 (USD 9.3) per month for the treatment of malaria. This is about Naira 427 (USD 3.6) in excess of the average expenditure they currently make on malaria treatment per month. Similarly, households are willing to pay on the average a sum of Naira 7,324 (USD 61) per month for the control of malaria. Again, this is an excess of about Naira 2,715 (USD 22.6) over the cost they currently bear (protection, treatment and indirect costs), and it represents households' average valuation of their intangible costs of malaria illness. This amount represents about Naira 611.7 (USD 5.1) per head per month and Naira 7,340 (USD 61.2) per year. For a country with a population of about 120 million this translates to about Naira 880,801 million per annum representing about 12.0 per cent of Gross Domestic Product. Hence, the malaria burden in Nigeria is enormous and has a devastating impact on economic growth. CONCLUSION: In the long term, it is important to recognize that health and poverty are closely linked. Reducing the burden of malaria in Nigeria will help to contribute to the economic well-being of communities; and poverty-reduction will be an essential input into improving health. National malaria control programme in Nigeria and their partners need to recognize these links, and identify mechanisms for ensuring that the poorest have access to essential health interventions.