Background: As the drive towards universal coverage is gaining momentum globally, the need for assessing levels of financial health protection in countries, particularity the developing world, has increasingly become important. In Swaziland, the level of financial health protection is not clearly understood. Objective: To assess financial catastrophe and impoverishment from out-of-pocket payments for health services in Swaziland. Methods: The nationally representative Swaziland Household Income and Expenditure Survey (2009/2010) dataset is used for the analyses. Data are collected by the Central Statistics Office in Swaziland. The final dataset contains information on 3,167 households (i.e. about 14,145 individuals) out of the anticipated 3,750 households. Financial catastrophe is assessed using an initial threshold that is adjusted to increase with household income (i.e. rank-dependent). Payment for health services is considered catastrophic when they exceed the threshold. Impoverishment is assessed using a national poverty line and an international poverty line ($1.25/day). Results: Using an initial threshold of 10.0% of household expenditure, 9.7% of Swazi households experience financial catastrophe while the proportion is estimated at 2.7% using an initial threshold of 40.0% of non-food expenditure. Between 1.0% and 1.6% of the Swazi population, representing between 10,000 and 16,000 people are pushed below the poverty line because of out-of-pocket payments. These findings indicate that financial health protection is not adequate in Swaziland. Conclusion: If Swaziland is to move towards achieving universal health coverage, there is a need to address the burden created by direct out-of-pocket payments. Among other things, this means that the country needs to consider financing mechanisms that guarantee equitable access to needed quality health services, which do not place undue hardship on the poor and vulnerable.

Background Cervical cancer imposes considerable economic burden on societies and individuals. There is lack of evidence regarding this from the developing world and particularly from sub-Saharan Africa. Therefore, the study aimed to estimate the societal costs of cervical cancer in Eswatini. Materials and methods The cost of illness study (CoI) was applied using national specific clinical and registry data from hospitals, registries and reports to determine the prevalence of cervical intraepithelial neoplasia (CIN) and cervical cancer in Eswatini in 2018. Cost data included direct medical costs (health care utilization in inpatient and outpatient care), direct non-medical costs (patient costs for traveling) and indirect costs based on productivity loss due to morbidity (patient time during diagnosis and treatment) and premature mortality. Results The estimated total annual cost for cervical cancer was $19 million (ranging between $14 million and $24 million estimated with lower and upper bounds). Direct cost represented the majority of the costs at 72% ($13.7 million) out of which total pre-cancerous treatment costs accounted for 0.7% ($94,161). The management of invasive cervical cancer was the main cost driver with costs attributable to treatment for FIGO III and FIGO IV representing $1.7 million and $8.7 million respectively. Indirect costs contributed 27% ($5.3 million) out of which productivity loss due to premature mortality represented the majority at 67% ($3.5 million). Conclusion The economic burden of cervical cancer in Eswatini is substantial. National public health prevention strategies with prophylactic HPV vaccine and screening for cervical lesions should therefore be prioritized to limit the extensive costs associated with cervical cancer.

Background Low back pain (LBP) is a multifactorial and the most prevalent musculoskeletal disorder, whose economic burden is of global concern. Evidence suggests that the burden of LBP in increasing and will continue rising with the greatest burden occurring in low-and-middle-income-countries (LMICs). This study sought to determine the economic burden of LBP in KwaZulu-Natal, South Africa from the providers perspective. Methods We used a retrospective prevalence-based cost-of-illness methodology to estimate the direct medical cost of LBP. Direct medical costs constituted costs associated with healthcare utilisation in inpatient care, outpatient care, investigations, consultations, and cost of auxiliary devices. We used diagnostic-specific data obtained from hospital clinical reports. All identifiable direct medical costs were estimated using a top-down approach for costs associated with healthcare and a bottom-up approach for costs associated with inpatient and outpatient care. Results The prevalence of chronic low back pain CLBP was 24.3% (95% CI: 23.5–25.1). The total annual average direct medical costs associated with LBP was US$5.4 million. Acute low back pain (ALBP) and CLBP contributed 17% (US$0.92 million) and 83% (US$4.48 million) of the total cost, respectively. The per patient total annual average direct medical cost for ALBP and CLBP were US$99.43 and US$1,516.67, respectively. The outpatient care costs contributed the largest share (38.9%, US$2.10 million) of the total annual average direct medical cost, 54.9% (US$1.15 million) of which was attributed to nonsteroidal-anti-inflammatory drugs (NSAIDs). The total average cost of diagnostic investigations was estimated at US$831,595.40, which formed 15.4% of the average total cost. Conclusion The economic burden of LBP is high in South Africa. Majority of costs were attributed to CLBP. The outpatient care costs contributed the largest share percent of the total cost. Pain medication was the main intervention strategy, contributing more than half of the total outpatient costs. Measures should be taken to ensure guideline adherence. Focus should also be placed towards development of prevention measures to minimise the cost.

Background Prostate cancer is the fifth cause of cancer mortality among men worldwide. However, there is limited data on costs associated with prostate cancer in low- and middle-income countries particularly in the sub-Saharan region. From a societal perspective, this study aims to estimate the cost of prostate cancer in Eswatini. Methods This prevalence–based cost-of-illness study used diagnosis specific data from national registries to estimate costs associated to prostate cancer during 2018. The prevalence-based approach was used employing both top down and bottom up costing approaches. Costs data included health care utilization, transport, sick leave days and premature death. Results The total annual cost of prostate cancer was $6.2 million (ranging between $ 4.7 million and 7.8 million estimated with lower and upper bounds). Average cost-per patient for radiotherapy, chemotherapy and other non-medical direct costs (transport and lodging) were the highest cost drivers recording $16,648, $7,498 and $5,959 respectively whilst indirect costs including productive loss due to sick leave and pre-mature mortality was estimated at $58,320 and $113,760 respectively. Cost of managing prostate cancer increased with advanced disease and costs were highest for prostate cancer stages III and IV recording $1.1million, $1.9million respectively. Conclusions Prostate cancer is a public health concern in Eswatini, and it imposes significant economic burden to the society. This finding point areas for policy makers to perform cost containment regarding therapeutic procedures for prostate cancer and the need for strategies to increase efficiencies in the health care systems for increased value for health care services.

PURPOSE Breast cancer (BC) is detected at late stages in sub-Saharan Africa. We piloted a BC early-detection program in Eswatini aimed at increasing breast health knowledge and clinical skills. We also aimed to determine the proportion of patients with breast abnormalities who completed referral to breast specialty clinics. METHODS Nurses and counselors from five human immunodeficiency virus and/or antiretroviral therapy clinics underwent training in BC and clinical breast examination (CBE). We compared knowledge and skill examinations completed before, immediately after, and 90 days after training. Nurses then screened female clinic patients ≥ 18 years for breast symptoms, examined those with symptoms, and referred women with CBE abnormalities to a surgeon or the national breast clinic. Consenting women were contacted at 30 and 60 days after screening to determine if they had completed referral. RESULTS In 2019, 44 nurses underwent training. Median scores (interquartile range) on pretraining, immediate post-training, and 90-day post-training knowledge examinations were 17.5 (16-19), 20 (19-21), and 20 (19-21), respectively. Median scores (interquartile range) on pretraining, immediate post-training, and 90-day post-training skills examinations were 10 (7-11), 23 (21.5-25), and 23 (22-24), respectively. Compared with pretraining scores, post-training scores were significantly improved ( P < .0001 for all comparisons). From June 2019 to April 2020, a total of 9,502 clinic patients were screened for breast symptoms: 150 (2%) underwent CBE, 93 (62%) were referred for further evaluation, and 88 (97%) were included in the study. Of those, 54 (61%) completed referral. Referral completion was not associated with age, employment, relationship status, or prior experiences related to BC. CONCLUSION The program's training curriculum improved breast health knowledge and clinical skills. Efforts are needed to improve patients' receipt of recommended evaluation for breast abnormalities.