Biomedical subjects

Kara Hanson

Publications and source records attributed to Kara Hanson.

At least 19 recordsLinked to original sources

PubMed2006

The impact of micro health insurance on Rwandan health centre costs.

While the implications of payment mechanisms for provider behaviour and cost have been amply explored in industrialized countries, there is little empirical evidence from developing countries. This study exploits the opportunities created by a pilot study of micro health insurance with capitation in Rwanda to address this issue. Using cross-sectional data collected in 52 health centres, the paper employs an econometric cost function with payer-specific outputs to assess the cost impact of two provider payment mechanisms: (1) user fees for care paid by the uninsured, and (2) capitation payment paid by informal insurance schemes for the insured. The cost function allows payer-specific marginal and average costs and scale measures to be calculated. Findings point to significant differences in cost between the two payment forms. These may be due to the incentives embodied in the capitation provider payment or the less severe case-mix among insured patients arising from improved access to care for this group, or both. For both payment types there are important short-run economies of scale, which could be exploited through more intensive use of idle resources in health centres.

Community Health Centers↗

PubMed2006

Two-tier charging strategies in public hospitals: implications for intra-hospital resource allocation and equity of access to hospital services.

Two-tier charging, the practice of offering separate qualities of service at different prices, is a growing practice in public hospitals internationally. This paper models two-tier charging as a Stackelberg game in which the Ministry of Health leads by setting prices and a representative hospital follows by setting quality levels to maximise surplus in response. Whether or not two-tier charging will secure cross-subsidy from superior to basic service users depends on the own and cross-quality effects of the demand functions for the two services. Under a range of assumptions, the policy will evoke cross-subsidy from basic to superior services.

Fees and Charges↗

PubMed2006

Costing the distribution of insecticide-treated nets: a review of cost and cost-effectiveness studies to provide guidance on standardization of costing methodology.

BACKGROUND: Insecticide-treated nets (ITNs) are an effective and cost-effective means of malaria control. Scaling-up coverage of ITNs is challenging. It requires substantial resources and there are a number of strategies to choose from. Information on the cost of different strategies is still scarce. To guide the choice of a delivery strategy (or combination of strategies), reliable and standardized cost information for the different options is required. METHODS: The electronic online database PubMed was used for a systematic search of the published English literature on costing and economic evaluations of ITN distribution programmes. The keywords used were: net, bednet, insecticide, treated, ITN, cost, effectiveness, economic and evaluation. Identified papers were analysed to determine and evaluate the costing methods used. Methods were judged against existing standards of cost analysis to arrive at proposed standards for undertaking and presenting cost analyses. RESULTS: Cost estimates were often not readily comparable or could not be adjusted to a different context. This resulted from the wide range of methods applied and measures of output chosen. Most common shortcomings were the omission of certain costs and failure to adjust financial costs to generate economic costs. Generalisability was hampered by authors not reporting quantities and prices of resources separately and not examining the sensitivity of their results to variations in underlying assumptions. CONCLUSION: The observed shortcomings have arisen despite the abundance of literature and guidelines on costing of health care interventions. This paper provides ITN specific recommendations in the hope that these will help to standardize future cost estimates.

Animals↗

PubMed2006

Horizontal equity in utilisation of care and fairness of health financing: a comparison of micro-health insurance and user fees in Rwanda.

This paper uses two methods to compare the impact of health care payments under insurance and user fees. Concentration indices for insured and uninsured groups are computed following the indirect standardisation method to evaluate horizontal inequity in utilisation of basic health care services. The minimum standard approach analyses the extent to which out-of-pocket health spending contributed to increased poverty. The analysis uses cross-sectional household survey data collected in Rwanda in 2000 in the context of the introduction of community-based health insurance. Results indicate that health spending had a small impact on the socio-economic situation of uninsured and insured households; however, this is at the expense of horizontal inequity in utilisation of care for user-fee paying individuals who reported significantly lower visit rates than the insured.

Cost Sharing↗

PubMed2006

Some indicators of socio-economic status may not be reliable and use of indices with these data could worsen equity.

Socio-economic status (SES) indices are increasingly being used to characterise (in)equity, with the assumption that SES indices are reliable. However, the accuracy of such SES indices is questionable if they are unreliable. We examined the inter-rater and test-retest reliability of a range of indicators commonly used to generate SES indices as well as the composite SES indices. Results from research in southeast Nigeria showed considerable variation, with some indicators having only low to moderate reliability (reliability coefficients 0.25-0.77). Inter-rater and test-retest reliability of SES indices was 0.63 in both cases. Many households were misclassified because of the unreliable SES indices. Analyses of the distribution of resources based on such indicators could lead to inaccuracies in benefit incidence estimates and policy decisions based on low to moderately reliable SES indicators could worsen equity in access to and use of resources. Greater rigour is needed in conceptualising as well as undertaking SES measurements.

Humans↗

PubMed2006

To retain or remove user fees?: reflections on the current debate in low- and middle-income countries.

Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care. It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option. Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.

Community Health Services↗

PubMed2005

Inter-rater and test-retest reliability of three contingent valuation question formats in south-east Nigeria.

This paper examines the inter-rater and test-retest reliability of willingness to pay (WTP) for insecticide-treated mosquito nets and net re-treatment using the bidding game (BG), binary with follow-up (BWFU) and a novel structured haggling technique (SH). Inter-rater reliability was evaluated by having two sets of interviewers administer questionnaires to 109 (BG), 110 (BWFU) and 103 (SH) randomly selected household heads. Test-retest reliability was investigated by repeating interviews on 146 (BG), 161 (BWFU) and 139 (SH) household heads one month after an initial survey. Data analysis used testing of means, Spearman's correlation and Pearson's correlation coefficient for test of reliability, while non-parametric analysis was used to determine factors causing a variation in WTP. The study was conducted in Southeast Nigeria. Inter-rater reliability coefficients were estimated for the individual's WTP for own nets, WTP for others and WTP for re-treatment. Using WTP for own nets as the best reliability estimate, the coefficients were high at values of 0.77 (C.I. 0.72-0.86), 0.75 (C.I. 0.64-0.81) and 0.74 (C.I. 0.63-0.82) in the BG, BWFU and SH, respectively. In test-retest reliability coefficients, the coefficients for WTP for own nets were low-to-moderate at values of 0.51 (C.I. 0.40-0.62), 0.41 (C.I. 0.28-0.53) and 0.56 (C.I. 0.41-0.65) for the BG, BWFU and SH groups, respectively. Factors such as gender, change in income, unplanned expenditures, stated WTP in first survey, time-to-think, external information, and subjecting respondents to more than one interview explained the lower test-retest reliability coefficients. We conclude that the CVM was reliable in the study area and the question formats had similar levels of reliability. The lower coefficients in the test-retest reliability were due to the influence of factors affecting demand that had changed in the intervening period. Standard formats for determining reliability within CVM should be developed for easy comparison of results from different studies.

Animals↗

PubMed2005

Preferences for hospital quality in Zambia: results from a discrete choice experiment.

This study reports on the results of a discrete choice experiment undertaken in Zambia to assess the factors influencing the demand for hospital care in Zambia, in particular the role of (perceived) quality and trade-offs between price and quality. Valuations of quality were evaluated for the treatment of two acute medical conditions, cerebral malaria in adults and acute pneumonia in children. Marginal utilities and willingness-to-pay for attributes of quality of hospital care were estimated, together with the influence of socioeconomic characteristics on these valuations and the extent of non-linearities in valuations of time and money. We find the technical quality of care, as represented by the thoroughness of examination, to be the most important quality attribute, followed by staff attitudes and drug availability. Valuations of examination thoroughness increase with increasing socioeconomic status. The disutility of cost was found to decrease with higher socioeconomic status, as was the value of drug availability. The implications of the findings for Zambian hospital sector reforms are discussed.

Adult↗

PubMed2005

The economics of social marketing: the case of mosquito nets in Tanzania.

There is a growing appreciation of the role of the private sector in expanding the use of key health interventions. At the policy level, this has raised questions about how public sector resources can best be used to encourage the private sector in order to achieve public health impact. Social marketing has increasingly been used to distribute public health products in developing countries. The Kilombero and Ulanga Insecticide-Treated Net Project (KINET) project used a social marketing approach in two districts of Tanzania to stimulate the development of the market for insecticide-treated mosquito nets (ITNs) for malaria control. Using evidence from household surveys, focus group discussions and a costing study in the intervention area and a control area, this paper examines two issues: (1) How does social marketing affect the market for ITNs, where this is described in terms of price and coverage levels; and (2) What does the added cost of social marketing "buy" in terms of coverage and equity, compared with an unassisted commercial sector model? It appears that supply improved in both areas, although there was a greater increase in supply in the intervention area. However, the main impact of social marketing on the market for nets was to shift demand in the intervention district, leading to a higher coverage market outcome. While social marketing was more costly per net distributed than the unassisted commercial sector, higher overall levels of coverage were achieved in the social marketing area together with higher coverage of the lowest socioeconomic group, of pregnant women and children under 5 years, and of those living on the periphery of their villages. These findings are interpreted in the context of Tanzania's national plan for scaling up ITNs.

Animals↗

PubMed2005

Do divergences between stated and actual willingness to pay signify the existence of bias in contingent valuation surveys?

This study's objective is to determine the factors that cause divergences over time (differences) between stated willingness to pay (WTP) and actual WTP (purchase behaviour), and consider whether any divergence signifies the presence of bias in contingent valuation studies. Stated WTP for insecticide-treated bed-nets (ITNs) was elicited from a random sample of respondents using three question formats in Nigeria. The question formats were the bidding game (BG), binary with follow-up (BWFU) and a novel structured haggling (SH) technique. The sales of the nets and a second survey were conducted 1 month after the first survey. In the second survey, factors that might explain the divergences were built into the questionnaire and these together with socio-economic variables were examined for causes of divergences in WTP. Data were analysed using non-parametric tests, testing of means and cross-tabulations. There were divergences in WTP in all three question formats: 69.4% in the BG, 78.7% in the BWFU and 48.8% in the SH. The higher the stated WTP, the more likely the divergence between stated and actual WTP. The attitude of the community leaders to the ITNs in the BG (p<0.05), the time respondents had to think about their WTP (p<0.05) and the external information they received about the ITNs in the BWFU (p<0.05) all led to divergences in WTP. We conclude that there are genuine causes of divergences between stated and actual WTP across the three question formats, and that the lesser the criterion validity score, the more the level of divergence in WTP. Studies that compare stated and actual WTP should explicitly determine the causes of divergences in order to assess the role of bias in the divergences.

Bedding and Linens↗

PubMed2005

Which delivery systems reach the poor? A review of equity of coverage of ever-treated nets, never-treated nets, and immunisation to reduce child mortality in Africa.

Insecticide-treated nets (ITNs) and childhood vaccination are two of the most powerful interventions available to prevent childhood mortality in Africa, but ITN coverage is still very low. Current debates about how to increase ITN coverage are concerned with the roles of different supply and delivery systems, in particular whether or not commercial net markets have any useful role. Here, we review data available on coverage and equity of coverage of three interventions to prevent childhood mortality. We compiled and analysed data from nationally representative surveys in 26 African countries to compare equity of coverage of (1) the Expanded Programme on Immunisation (EPI), (2) any net, (3) ever-treated nets (ie, ITNs), and (4) never-treated nets (ie, untreated nets; UTNs). We assumed that ever-treated net coverage mostly reflects the activities of public-health programmes and projects, and that never-treated net coverage mostly reflects the activity of local unsubsidised commercial markets. We discuss the validity, limitations, and possible biases of these assumptions. We estimate that 87% of the 8.4 million children protected by nets used UTNs. We used the concentration index (CI) to assess equity of coverage of the interventions. The data shows that never-treated net coverage is surprisingly equitable: overall, and despite substantial regional variations, it is comparable in equity to EPI (median CI(UTN)=0.166, CI(EPI)=0.075; p=0.3). In almost all countries, coverage of ITNs is strongly concentrated in the least poor households, and significantly more inequitable than both UTNs (median CI(ITN)=0.435, mean CI(UTN)=0.158; p<0.001) and EPI (median CI(ITN)=0.435, CI(EPI)=0.075; p<0.001). These results suggest that the public-health value of commercial net markets has been greatly underestimated, and that these markets have so far contributed more to equitable and sustainable coverage of mosquito nets, and hence to the prevention of malaria in Africa, than have the ITNs delivered by public-health systems and projects.

Africa↗

PubMed2005

Is malaria a disease of poverty? A review of the literature.

OBJECTIVE: To review the evidence on the link between malaria and poverty. METHODS: Review of the published and grey literature to identify (i) the data available on the socio-economic distribution of malaria incidence and vulnerability, and (ii) the uptake of malaria control interventions. RESULTS: We found mixed evidence on malaria incidence, with a number of studies identifying no relationship between socio-economic status and incidence, although a larger number of studies do find a link. There is strong evidence that uptake of preventive and treatment interventions is closely related to proxies for socio-economic status. More generally, the quality of the literature examining this issue is highly variable, with many different measures of socio-economic status and often inadequate descriptions of methods of data collection and analysis in relation to socio-economic status. CONCLUSIONS: Important socio-economic differentials exist in access to malaria interventions, increasing the vulnerability of the poorest. More information is needed about how other methods of delivering malaria treatment and prevention can redress these inequalities.

Africa↗

PubMed2004

Inequalities in purchase of mosquito nets and willingness to pay for insecticide-treated nets in Nigeria: challenges for malaria control interventions.

OBJECTIVE: To explore the equity implications of insecticide-treated nets (ITN) distribution programmes that are based on user charges. METHODS: A questionnaire was used to collect information on previous purchase of untreated nets and hypothetical willingness to pay (WTP) for ITNs from a random sample of householders. A second survey was conducted one month later to collect information on actual purchases of ITNs. An economic status index was used for characterizing inequity. MAJOR FINDINGS: The lower economic status quintiles were less likely to have previously purchased untreated nets and also had a lower hypothetical and actual WTP for ITNs. CONCLUSION: ITN distribution programmes need to take account of the diversity in WTP for ITNs if they are to ensure equity in access to the nets. This could form part of the overall poverty reduction strategy.

Animals↗

PubMed2004

Price discrimination in obstetric services--a case study in Bangladesh.

This article examines the existence of price discrimination for obstetric services in two private hospitals in Bangladesh, and considers the welfare consequences of such discrimination, i.e. whether or not price discrimination benefited the poorer users. Data on 1212 normal and caesarean section patients discharged from the two hospitals were obtained. Obstetric services were chosen because they are relatively standardised and the patient population is relatively homogeneous, so minimising the scope and scale of product differentiation due to procedure and case-mix differences. The differences between the hospital list price for delivery and actual prices paid by patients were calculated to determine the average rate of discount. The welfare consequences of price discrimination were assessed by testing the differences in mean prices paid by patients from three income groups: low, middle and high. The results suggest that two different forms of price discrimination for obstetric services occurred in both these hospitals. First, there was price discrimination according to income, with the poorer users benefiting from a higher discount rate than richer ones; and second, there was price discrimination according to social status, with three high status occupational groups (doctors, senior government officials, and large businessmen) having the highest probability of receiving some level of discount.

Bangladesh↗

PubMed2004

The impact of quality on the demand for outpatient services in Cyprus.

Health policy reforms in a number of countries seek to improve provider quality by sharpening the incentives they face, for example by exposing them to greater competition. For this to succeed, patients must be responsive to quality in their choice of provider. This paper uses data from Cyprus to estimate the effect of quality on patients' choice between public and private outpatient care. It improves on the existing literature by using a more comprehensive set of quality attributes which allows the dimensions of quality that have the largest effect on patient choice of provider to be identified. We also introduce an innovative way of measuring patients' perceptions of quality in a household survey. We find that patients' choice of provider is sensitive to quality, and that interpersonal quality is more important than either technical quality or system-related factors.

Ambulatory Care↗

PubMed2004

Valuing the benefits of a health intervention using three different approaches to contingent valuation: re-treatment of mosquito bed-nets in Nigeria.

OBJECTIVES: To determine the level of willingness to pay (WTP) for re-treatment of mosquito nets and to compare the theoretical validity of WTP estimates from three contingent valuation question formats: the bidding game, binary with follow-up technique, and a novel structured haggling technique that mimicked price-taking behaviour in the study area. METHODS: WTP was elicited from randomly selected respondents from three villages in Southeast Nigeria, using pretested interviewer-administered questionnaires. Respondents' WTP for insecticide-treated nets (ITNs) was first elicited before their WTP for re-treatment of ITNs. Ordinary least-squares regression was used to assess theoretical validity. RESULTS: More than 95% of the respondents were willing to pay for re-treatment. The mean WTP was 37.1 Naira, 43.4 Naira and 49.2 Naira in the bidding game, binary with follow-up and structured haggling groups, respectively (US dollar 1.00 = 120 Naira). The WTP estimates elicited across the three question formats were statistically different (P < 0.01). Ordinary least-squares estimation showed that WTP was positively related to many variables, especially stated WTP for ITNs (P < 0.05). Structured haggling generated the highest number of statistically significant variables to explain WTP. CONCLUSIONS: The three contingent valuation approaches generated different distributions of WTP for net retreatment, possibly due to their inherent differences. Structured haggling generated the most theoretically valid estimates of WTP. The levels of WTP identified suggest that user fees exceeding 50 Naira per net re-treatment may discourage demand for the service. This is an important challenge for ITN programmes.

Adult↗

PubMed2004

Public and private roles in malaria control: the contributions of economic analysis.

There has been high profile advocacy and debate about how to increase availability and uptake of effective malaria control interventions. Application of the tools of public economics indicates that market failures occur for a number of effective malaria control interventions due to monopoly, externalities, and information failures, implying a role for public action. However, additional analysis is required to determine the optimal form of public intervention, and how to set priorities. Additional criteria of cost-effectiveness, impact on poverty and catastrophic expenditures, affordability, characteristics of supply and demand, and potential for leakage are invoked to help inform decision making in the field of malaria control policies. Particular emphasis is placed on the connections between public and private actions.

Cost-Benefit Analysis↗

PubMed2004

Do malaria control interventions reach the poor? A view through the equity lens.

Malaria, more than any other disease of major public health importance in developing countries, disproportionately affects poor people, with 58% of malaria cases occurring in the poorest 20% of the world's population. If malaria control interventions are to achieve their desired impact, they must reach the poorest segments of the populations of developing countries. Unfortunately, a growing body of evidence from benefit-incidence analyses has demonstrated that many public health interventions that were designed to aid the poor are not reaching their intended target. For example, the poorest 20% of people in selected developing countries were as much as 2.5 times less likely to receive basic public health services as the least-poor 20%. In the field of malaria control, a small number of studies have begun to shed light on differences by wealth status of malaria burden and of access to treatment and prevention services. These early studies found no clear difference in fever incidence based on wealth status, but did show significant disparities in both the consequences of malaria and in the use of malaria prevention and treatment services. Further study is needed to elucidate the underlying factors that contribute to these disparities, and to examine possible inequities related to gender, social class, or other factors. To achieve impact and overcome such inequities, malaria control efforts must begin to incorporate approaches relevant to equity in program design, implementation, and monitoring and evaluation.

Delivery of Health Care↗