The impact and cost-effectiveness of user fee exemption by contracting out essential health package services in Malawi

Zeng, Wu; Sun, Daxin; Mphwanthe, Henry; Huan, Tianwen; Nam, Jae Eun; Saint-Firmin, Pascal; Manthalu, Gerald; Sharma, Siddharth; Dutta, Arin

doi:10.1136/bmjgh-2018-001286

Cited by 12 publications

(18 citation statements)

References 19 publications

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“…Despite preventive care being the mandate of primary healthcare facilities, majority of RHCs showed a decline in immunization coverage rates. This is a consistent finding in studies from Malawi and Guatemala that have reported similar pattern (20,25). While this might indicate an abundance of focus on curative care, it could also be attributed to incoherence amongst NSP and DHO office.…”

Section: Discussionsupporting

confidence: 91%

“…However, preventive services such as immunization showed inconsistent results with decline at most of the healthcare facilities. Studies from countries such as Malawi (20), India (21) and Cambodia (22) have reported similar results regarding utilization of health services.…”

Section: Discussionmentioning

confidence: 68%

“…Given the severity of the problem and global attention given to maternal health issues, indicators such as ANC and PNC were explicitly stated as KPIs in the service delivery contract. Studies from Malawi (20), India (21) and Cambodia (22) have shown a similar increase in service utilization. Being a priority health issue, it also received attention in health workforce leading to increased number of general female doctors and specialist doctors such as gynecologists/obstetricians hence partly explaining the increased service utilisation.…”

Section: Discussionmentioning

confidence: 73%

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Contracting out of health services improves service utilization and satisfaction: evidence from rural districts of Pakistan

Abbasi¹,

Fatmi²

2020

Preprint

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Background Contracting out of health services to non-state providers has been widely used in developing countries including Pakistan. Based on three years’ experience of contracting out primary and secondary health services, this paper presents findings of third party evaluation of health services from two rural districts of Sindh Pakistan. Methods This was a baseline vs end-line cross sectional assessment of thirteen primary and secondary healthcare facilities from two rural districts (Thatta and Sujawal) of Sindh province that were contracted out in 2016 to a national non-governmental organization. Healthcare facilities included: 8 rural health centres, 4 taluka headquarter hospitals and 1 district headquarter hospital. District health information system was used to extract three years (2016 – 2019) data on key performance indicators (KPIs) as agreed in contract. We conducted record review related to human resource and budget and in-depth interviews with health managers. Health facility assessment survey and client satisfaction exit interviews were also conducted. Results KPIs showed significant improvement in service provision from baseline. General outpatient department (OPD) (33%), specialist OPD (91%), accident/emergency consultations (106%), in-patient admissions (≥100%) alongside diagnostic/laboratory service utilization (86%) increased substantially. Facility based deliveries (37%), and major (99%) and minor (172%) surgeries also showed significant increase. Preventive services (maternal tetanus toxoid, child vaccination) showed modest improvement (4-19%) in the district (overall) but slight decline in some healthcare facilities. Slight improvement in specialist workforce care was noticed, however challenges related to staff retention persisted. Adequate supplies and equipment were available except radiology services. Most healthcare facilities were also in need of repair. Delayed and partial release of funds by government was a major barrier. Lack of coordination among different stakeholders delivering healthcare in the district was also noted. Majority of clients (60%) were satisfied with service delivery but unavailability of medicine was their main concern. Conclusions Contracting out has the potential to improve service utilization. Autonomy over budget allocation and utilization, appointment of all cadre of staff, and improved coordination among all stakeholders is required to improve service delivery. Quality of care and the longer term health outcomes need further evaluation.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 68%

Section: Discussionmentioning

confidence: 73%

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Contracting out of health services improves service utilization and satisfaction: evidence from rural districts of Pakistan

Abbasi¹,

Fatmi²

2020

Preprint

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“…Such reduction is speculated to be related to internal political instability, scandals and poor governances [59,65]. Strategies that include fee-based, non-profitable health providers working in rural areas mitigates financial barriers to use of care and expands the options for higher-level health providers that poor remote dwellers are otherwise unable to use, thus shortening the travel time required to obtain and receive adequate care [66,67]. Long-term implementation of these strategies should not be hampered by unfavourable policy environment and government challenges.…”

Section: Interpretation Of Resultsmentioning

confidence: 99%

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

Wong

Brady

Campbell

et al. 2020

Int J Equity Health

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Background: In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries. Methods: We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors. Results: The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play. Conclusions: Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.

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“…This observation suggests that free care policy at the point of use in Malawi is likely to have fostered equality in distributing public spending for curative and institutional delivery services. The free care at public facilities and CHAM facilities through SLA contracts with the Malawi government has likely translated into the steady increase of the use of curative [26] and maternal [44,45] services. Similar ndings were reported by two studies conducted in India, which revealed that the introduction of the Janani Suralesha Yojana (JSY) policy enabling access to institutional delivery free of charge fostered equality in public health spending [46,47].…”

Section: Discussionmentioning

confidence: 99%

How Equitable Is Health Spending On Curative Services And Institutional Delivery In Malawi? Evidence From A Quasi-Longitudinal Benefit Incidence Analysis

Rudasingwa¹,

Yeboah²,

Ridde³

et al. 2021

Preprint

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Background: Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016.Methods: We relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group. Results: Socioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively. Conclusion: Through its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection.

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The impact and cost-effectiveness of user fee exemption by contracting out essential health package services in Malawi

Cited by 12 publications

References 19 publications

Contracting out of health services improves service utilization and satisfaction: evidence from rural districts of Pakistan

Contracting out of health services improves service utilization and satisfaction: evidence from rural districts of Pakistan

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

How Equitable Is Health Spending On Curative Services And Institutional Delivery In Malawi? Evidence From A Quasi-Longitudinal Benefit Incidence Analysis

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