Health expenditure: how much is spent on health and care worker remuneration? An analysis of 33 low- and middle-income African countries.

OBJECTIVES: To assess the amount spent on health and care workforce (HCW) remuneration in the African countries, its importance as a proportion of country expenditure on health, and government involvement as a funding source. METHODS: Calculations are based on country-produced disaggregated health accounts data from 33 low- and middle-income African countries, disaggregated wherever possible by income and subregional economic group. RESULTS: Per capita expenditure HCW remuneration averaged US$ 38, or 29% of country health expenditure, mainly coming from domestic public sources (three-fifths). Comparable were the contributions from domestic private sources and external aid, measured at around one-fifth each-23% and 17%, respectively. Spending on HCW remuneration was uneven across the 33 countries, spanning from US$ 3 per capita in Burundi to US$ 295 in South Africa. West African countries, particularly members of the West African Economic and Monetary Union (WAEMU), were lower spenders than countries in the Southern African Development Community (SADC), both in terms of the share of country health expenditure and in terms of government efforts/participation. By income group, HCW remuneration accounted for a quarter of country health expenditure in low-income countries, compared to a third in middle-income countries. Furthermore, an average 55% of government health expenditure is spent on HCW remuneration, across all countries. It was not possible to assess the impact of fragile and vulnerable countries, nor could we draw statistics by type of health occupation. CONCLUSIONS: The results clearly show that the remuneration of the health and care workforce is an important part of government health spending, with half (55%) of government health spending on average devoted to it. Comparing HCW expenditure components allows for identifying stable sources, volatile sources, and their effects on HCW investments over time. Such stocktaking is important, so that countries, WHO, and other relevant agencies can inform necessary policy changes.

Resource tracking for neglected tropical disease programmes: the first step for developing a sustainable financing strategy.

The adequacy of resources for programme implementation is a premise for achieving the targets set in the road map for neglected tropical diseases (NTDs) 2021-2030. During the decade 2010-2020, international health aid and pharmaceutical donations have driven progress to control and eliminate NTDs. In the next decade, domestic financing will be critical to sustain NTD control and elimination programmes. Tracking domestic resources for NTD programmes through country health accounts, a relatively mature health system resource tracking platform, could be the first step in raising the visibility of NTDs in the discussion of national health resource allocation.

Public sector services for the prevention of mother-to-child transmission of HIV infection: a micro-costing survey in Namibia and Rwanda.

OBJECTIVE: To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries. METHODS: In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$). FINDINGS: The estimated costs to the providers of PMTCT, for each mother-infant pair, were US$202.75-1029.55 in Namibia and US$94.14-342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$3.15 million in Namibia and US$7.04 million in Rwanda (or < US$0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries. CONCLUSION: The costs involved in the PMTCT of HIV varied widely between study countries and in accordance with the protocols used. However, since per-capita costs were relatively low, the scaling up of PMTCT services in Namibia and Rwanda should be possible.

Nevirapine for the prevention of mother-to-child transmission of HIV: a nation-wide coverage survey in Côte d'Ivoire.

BACKGROUND: Single-dose nevirapine (NVP) is the simplest antiretroviral regimen for the prevention of mother-to-child HIV transmission (PMTCT) in resource-limited settings. We evaluated NVP coverage among HIV-infected delivering women in Côte d'Ivoire. METHODS: A cross-sectional survey of mother-infant pairs was conducted between November 2007 and September 2008 in 10 randomly selected facilities providing delivery services in the country. All sites used at least NVP for PMTCT. Anonymous HIV test and blood collection for NVP concentration measurement were performed in labor wards. NVP coverage was defined as the proportion of maternal and infant NVP intake confirmed by cord blood chromatography and direct observation. RESULTS: A total of 9953 deliveries were enrolled. Median maternal age was 25 years, and the median number of antenatal care (ANC) visits was 3. Of the 9747 women (97.9%) who made at least 1 ANC visit, 5880 (60.3%) received an HIV test proposal, 5135 (87.3%) accepted it, and 251 (4.9%) were diagnosed HIV infected; 176 of them (70.1%) received antiretroviral prophylaxis according to the medical record. Using anonymous cord blood surveillance, HIV prevalence was 5.9% (570 of 9646), maternal NVP coverage was 24.3% (138 of 570), and maternal and infant NVP coverage was 17.9% (102 of 570). In multivariate analysis, maternal NVP coverage was associated with 2-3 ANC visits [adjusted odds ratio (aOR): 2.61; 95% confidence interval (CI): 1.27 to 5.39] or ≥ 4 ANC visits (aOR: 3.84; 95% CI: 1.86 to 7.90) (ref. ≤ 1), and giving birth in clinic of first ANC visit (aOR: 2.21; 95% CI: 1.43 to 3.40). CONCLUSIONS: Maternal and infant NVP coverage was low irrespective of the method. Anonymous cord blood surveillance is more reliable for documenting PMTCT coverage.

To what extent could performance-based schemes help increase the effectiveness of prevention of mother-to-child transmission of HIV (PMTCT) programs in resource-limited settings? A summary of the published evidence.

BACKGROUND: In resource-limited settings, HIV/AIDS remains a serious threat to the social and physical well-being of women of childbearing age, pregnant women, mothers and infants. DISCUSSION: In sub-Saharan African countries with high prevalence rates, pediatric HIV/AIDS acquired through mother-to-child transmission (MTCT) can in largely be prevented by using well-established biomedical interventions. Logistical and socio-cultural barriers continue, however, to undermine the successful prevention of MTCT (PMTCT). In this paper, we review reports on maternal, neonatal and child health, as well as HIV care and treatment services that look at program incentives. SUMMARY: These studies suggest that comprehensive PMTCT strategies aiming to maximize health-worker motivation in developing countries must involve a mix of both financial and non-financial incentives. The establishment of robust ethical and regulatory standards in public-sector HIV care centers could reduce barriers to PMTCT service provision in sub-Saharan Africa and help them in achieving universal PMTCT targets.

Cost-effectiveness of preventing loss to follow-up in HIV treatment programs: a Côte d'Ivoire appraisal.

BACKGROUND: Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up (LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa. METHODS AND FINDINGS: We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infection-related drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health Organization criteria of <3x gross domestic product per capita (3x GDP per capita = US$2,823 for Côte d'Ivoire) as a plausible threshold for "cost-effectiveness." The main results are based on a reported 18% 1-y LTFU rate. With full retention in care, projected per-person discounted life expectancy starting from age 37 y was 144.7 mo (12.1 y). Survival losses from LTFU within 1 y of ART initiation ranged from 73.9 to 80.7 mo. The intervention costing US$22/person/year (e.g., eliminating ART co-payment) would be cost-effective with an efficacy of at least 12%. An intervention costing US$77/person/year (inclusive of all the components described above) would be cost-effective with an efficacy of at least 41%. CONCLUSIONS: Interventions that prevent LTFU in resource-limited settings would substantially improve survival and would be cost-effective by international criteria with efficacy of at least 12%-41%, depending on the cost of intervention, based on a reported 18% cumulative incidence of LTFU at 1 y after ART initiation. The commitment to start ART and treat HIV in these settings should include interventions to prevent LTFU.

Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America.

OBJECTIVES: To describe temporal trends in baseline clinical characteristics, initial treatment regimens and monitoring of patients starting antiretroviral therapy (ART) in resource-limited settings. METHODS: We analysed data from 17 ART programmes in 12 countries in sub-Saharan Africa, South America and Asia. Patients aged 16 years or older with documented date of start of highly active ART (HAART) were included. Data were analysed by calculating medians, interquartile ranges (IQR) and percentages by regions and time periods. Not all centres provided data for 2006 and 2005 and 2006 were therefore combined. RESULTS: A total of 36,715 patients who started ART 1996-2006 were included in the analysis. Patient numbers increased substantially in sub-Saharan Africa and Asia, and the number of initial regimens declined, to four and five, respectively, in 2005-2006. In South America 20 regimes were used in 2005-2006. A combination of 3TC/D4T/NVP was used for 56% of African patients and 42% of Asian patients; AZT/3TC/EFV was used in 33% of patients in South America. The median baseline CD4 count increased in recent years, to 122 cells/microl (IQR 53-194) in 2005-2006 in Africa, 134 cells/microl (IQR 72-191) in Asia, and 197 cells/microl (IQR 61-277) in South America, but 77%, 78% and 51%, respectively, started with <200 cells/microl in 2005-2006. In all regions baseline CD4 cell counts were higher in women than men: differences were 22cells/microl in Africa, 65 cells/microl in Asia and 10 cells/microl in South America. In 2005-2006 a viral load at 6 months was available in 21% of patients Africa, 8% of Asian patients and 73% of patients in South America. Corresponding figures for 6-month CD4 cell counts were 74%, 77% and 81%. CONCLUSIONS: The public health approach to providing ART proposed by the World Health Organization has been implemented in sub-Saharan Africa and Asia. Although CD4 cell counts at the start of ART have increased in recent years, most patients continue to start with counts well below the recommended threshold. Particular attention should be paid to more timely initiation of ART in HIV-infected men.