Health system cost of delivering routine vaccination in low- and lower-middle income countries: what is needed over the next decade?

Abstract Background Globally, Pediatric Intensive Care Unit (PICU) admissions are amongst the most expensive. In low middle-income countries, out of pocket expenditure (OOP) constitutes a major portion of the total expenditure. This makes it important to gain insights into the cost of pediatric intensive care. We undertook this study to calculate the health system cost and out of pocket expenditure incurred per patient during PICU stay. Methods Prospective study conducted in a state of the art tertiary level PICU of a teaching and referral hospital. Bottom-up micro costing methods were used to assess the health system cost. Annual data regarding hospital resources used for PICU care was collected from January to December 2018. Data regarding OOP was collected from 299 patients admitted from July 2017 to December 2018. The latter period was divided into four intervals, each of four and a half months duration and data was collected for 1 month in each interval. Per patient and per bed day costs for treatment were estimated both from health system and patient’s perspective. Results The median (inter-quartile range, IQR) length of PICU stay was 5(3–8) days. Mean ± SD Pediatric Risk of Mortality Score (PRISM III) score of the study cohort was 22.23 ± 7.3. Of the total patients, 55.9% (167) were ventilated. Mean cost per patient treated was US$ 2078(₹ 144,566). Of this, health system cost and OOP expenditure per patient were US$ 1731 (₹ 120,425) and 352 (₹ 24,535) respectively. OOP expenditure of a ventilated child was twice that of a non- ventilated child. Conclusions The fixed cost of PICU care was 3.8 times more than variable costs. Major portion of cost was borne by the hospital. Severe illness, longer ICU stay and ventilation were associated with increased costs. This study can be used to set the reimbursement package rates under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). Tertiary level intensive care in a public sector teaching hospital in India is far less expensive than developed countries.

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The Italian Health System: Cost Containment, Mismanagement, and Politicization

Italian Politics ◽

10.3167/ip.2008.240112 ◽

2009 ◽

Vol 24 (1) ◽

Cited By ~ 1

Author(s):

Franca Maino

Keyword(s):

Health System ◽

Cost Containment ◽

System Cost ◽

Health System Cost

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Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BMJ Global Health ◽

10.1136/bmjgh-2020-004324 ◽

2021 ◽

Vol 6 (5) ◽

pp. e004324

Author(s):

John Whitaker ◽

Nollaig O'Donohoe ◽

Max Denning ◽

Dan Poenaru ◽

Elena Guadagno ◽

...

Keyword(s):

Systematic Review ◽

Health System ◽

Evidence Synthesis ◽

Rapid Assessment ◽

Sub Saharan Africa ◽

Trauma Systems ◽

Middle Income ◽

Middle Income Countries ◽

Low Middle Income Countries ◽

Three Delays

BackgroundThe large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.MethodsWe conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.ResultsOf 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.ConclusionsWhole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

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Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda

Gates Open Research ◽

10.12688/gatesopenres.13214.1 ◽

2021 ◽

Vol 5 ◽

pp. 72

Author(s):

Lisa R. Hirschhorn ◽

Miriam Frisch ◽

Jovial Thomas Ntawukuriryayo ◽

Amelia VanderZanden ◽

Kateri Donahoe ◽

...

Keyword(s):

Health System ◽

Implementation Research ◽

Contextual Factors ◽

Common Pathway ◽

Middle Income ◽

Middle Income Countries ◽

Mixed Methods Case Study ◽

Hybrid Framework ◽

Successes And Challenges

Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) – deaths preventable through health system-delivered evidence-based interventions (EBIs) – in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification and testing of strategies, work to achieve sustainability at scale and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda’s actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country’s success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.

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Adding etonorgestrel implant in Indian health system cost effective

PharmacoEconomics & Outcomes News ◽

10.1007/s40274-020-7048-2 ◽

2020 ◽

Vol 860 (1) ◽

pp. 2-2

Keyword(s):

Health System ◽

Cost Effective ◽

System Cost ◽

Indian Health ◽

Health System Cost

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Understanding the challenges associated with the use of data from routine health information systems in low- and middle-income countries: A systematic review

Health Information Management Journal ◽

10.1177/1833358320928729 ◽

2020 ◽

pp. 183335832092872 ◽

Cited By ~ 1

Author(s):

Klesta Hoxha ◽

Yuen W Hung ◽

Bridget R Irwin ◽

Karen A Grépin

Keyword(s):

Information Systems ◽

Health System ◽

Health Information ◽

Health Information Systems ◽

Health System Strengthening ◽

Middle Income ◽

Environmental Challenges ◽

Middle Income Countries ◽

Data Process ◽

Low And Middle Income

Background: Routine health information systems (RHISs) are crucial to informing decision-making at all levels of the health system. However, the use of RHIS data in low- and middle-income countries (LMICs) is limited due to concerns regarding quality, accuracy, timeliness, completeness and representativeness. Objective: This study systematically reviewed technical, behavioural and organisational/environmental challenges that hinder the use of RHIS data in LMICs and strategies implemented to overcome these challenges. Method: Four electronic databases were searched for studies describing challenges associated with the use of RHIS data and/or strategies implemented to circumvent these challenges in LMICs. Identified articles were screened against inclusion and exclusion criteria by two independent reviewers. Results: Sixty studies met the inclusion criteria and were included in this review, 55 of which described challenges in using RHIS data and 20 of which focused on strategies to address these challenges. Identified challenges and strategies were organised by their technical, behavioural and organisational/environmental determinants and by the core steps of the data process. Organisational/environmental challenges were the most commonly reported barriers to data use, while technical challenges were the most commonly addressed with strategies. Conclusion: Despite the known benefits of RHIS data for health system strengthening, numerous challenges continue to impede their use in practice. Implications: Additional research is needed to identify effective strategies for addressing the determinants of RHIS use, particularly given the disconnect identified between the type of challenge most commonly described in the literature and the type of challenge most commonly targeted for interventions.

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Level of confidence in and endorsement of the health system among internet users in 12 low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2019-002205 ◽

2020 ◽

Vol 5 (8) ◽

pp. e002205

Author(s):

Sanam Roder-DeWan ◽

Anna Gage ◽

Lisa R Hirschhorn ◽

Nana A Y Twum-Danso ◽

Jerker Liljestrand ◽

...

Keyword(s):

Health System ◽

Low Income ◽

Internet Survey ◽

Health Coverage ◽

Middle Income ◽

Middle Income Countries ◽

Internet Users ◽

Effective Care ◽

Universal Health

IntroductionPeople’s confidence in and endorsement of the health system are key measures of system performance, yet are undermeasured in low-income and middle-income countries (LMICs). We explored the prevalence and predictors of these measures in 12 countries.MethodsWe conducted an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal and South Africa collecting demographics, ratings of quality, and confidence in and endorsement of the health system. We used multivariable logistic regression to assess the association between confidence/endorsement and self-reported quality of recent healthcare.ResultsOf 13 489 respondents, 62% reported a health visit in the past year. Applying population weights, 32% of these users were very confident that they could receive effective care if they were to ‘become very sick tomorrow’; 30% endorsed the health system, that is, agreed that it ‘works pretty well and only needs minor changes’. Reporting high quality in the last visit was associated with 4.48 and 2.69 greater odds of confidence (95% CI 3.64 to 5.52) and endorsement (95% CI 2.33 to 3.11). Having health insurance was positively associated with confidence and endorsement (adjusted odds ratio (AOR) 1.68, 95% CI 1.49 to 1.90 and AOR 1.34, 95% CI 1.22 to 1.48), while experiencing discrimination in healthcare was negatively associated (AOR 0.67, 95% CI 0.56 to 0.80 and AOR 0.63, 95% CI 0.53 to 0.76).ConclusionConfidence and endorsement of the health system were low across 12 LMICs. This may hinder efforts to gain support for universal health coverage. Positive patient experience was strongly associated with confidence in and endorsement of the health system.

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Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: a cross-country qualitative study

Epidemiology and Psychiatric Sciences ◽

10.1017/s2045796017000634 ◽

2017 ◽

Vol 27 (1) ◽

pp. 29-39 ◽

Cited By ~ 21

Author(s):

H. Lempp ◽

S. Abayneh ◽

D. Gurung ◽

L. Kola ◽

J. Abdulmalik ◽

...

Keyword(s):

Mental Health ◽

Health System ◽

Mental Health System ◽

Service User ◽

Health System Strengthening ◽

Service Users ◽

Middle Income ◽

Middle Income Countries ◽

Cross Country ◽

Caregiver Involvement

Aims.The aims of this paper are to: (i) explore the experiences of involvement of mental health service users, their caregivers, mental health centre heads and policy makers in mental health system strengthening in three low- and middle-income countries (LMICs) (Ethiopia, Nepal and Nigeria); (ii) analyse the potential benefits and barriers of such involvement; and (iii) identify strategies required to achieve greater service user and caregiver participation.Methods.A cross-country qualitative study was conducted, interviewing 83 stakeholders of mental health services.Results.Our analysis showed that service user and caregiver involvement in the health system strengthening process was an alien concept for most participants. They reported very limited access to direct participation. Stigma and poverty were described as the main barriers for involvement. Several strategies were identified by participants to overcome existing hurdles to facilitate service user and caregiver involvement in the mental health system strengthening process, such as support to access treatment, mental health promotion and empowerment of service users. This study suggests that capacity building for service users, and strengthening of user groups would equip them to contribute meaningfully to policy development from informed perspectives.Conclusion.Involvement of service users and their caregivers in mental health decision-making is still in its infancy in LMICs. Effective strategies are required to overcome existing barriers, for example making funding more widely available for Ph.D. studies in participatory research with service users and caregivers to develop, implement and evaluate approaches to involvement that are locally and culturally acceptable in LMICs.

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