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Today's uncertain HIV funding landscape threatens to slow progress towards treatment goals. Understanding the costs of antiretroviral therapy (ART) will be essential for governments to make informed policy decisions about the pace of scale-up under the 2013 WHO HIV Treatment Guidelines, which increase the number of people eligible for treatment from 17.6 million to 28.6 million. The study presented here is one of the largest of its kind and the first to describe the facility-level cost of ART in a random sample of facilities in Ethiopia, Malawi, Rwanda, South Africa and Zambia. In 2010-2011, comprehensive data on one year of facility-level ART costs and patient outcomes were collected from 161 facilities, selected using stratified random sampling. Overall, facility-level ART costs were significantly lower than expected in four of the five countries, with a simple average of $208 per patient-year (ppy) across Ethiopia, Malawi, Rwanda and Zambia. Costs were higher in South Africa, at $682 ppy. This included medications, laboratory services, direct and indirect personnel, patient support, equipment and administrative services. Facilities demonstrated the ability to retain patients alive and on treatment at these costs, although outcomes for established patients (2-8% annual loss to follow-up or death) were better than outcomes for new patients in their first year of ART (77-95% alive and on treatment). This study illustrated that the facility-level costs of ART are lower than previously understood in these five countries. While limitations must be considered, and costs will vary across countries, this suggests that expanded treatment coverage may be affordable. Further research is needed to understand investment costs of treatment scale-up, non-facility costs and opportunities for more efficient resource allocation.

Background Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014. Methods We conducted 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 at three time points. We combined data from household surveys and National Health Accounts. Results Results showed that public (concentration index of − 0.003; SE 0.027 in 2006 and − 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and − 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services. Conclusion Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care.

Background Sub-Saharan Africa suffers from the highest maternal mortality ratio (MMR) in the world, with 542 deaths per 100,000 live births in 2017, relative to a global ratio of 211. Reducing gender-based discrimination (GBD) and increasing the empowerment of women and girls have recently been recognized as prerequisites for improving maternal health. Previous studies have shown GBD to result in low utilization of maternal health services and poorer quality of care. However, limited research is available on the relationship between GBD and maternal mortality in Sub-Saharan Africa (SSA). Therefore, the objective of this study was to assess whether GBD is associated with maternal mortality in SSA. Methods We investigated the association between self-reported GBD and maternal mortality in an ecological study. We used data from two surveys: the Demographic and Health Surveys (DHS) and the Afrobarometer. Data refer to 78 sub-national regions, located in nine Sub-Saharan African countries (Benin, Malawi, Mali, Nigeria, Senegal, South Africa, Uganda, Zambia, and Zimbabwe). Data were analyzed using a two-level linear regression model with random intercept. The regression controlled for covariates at region- and country-level. Results The proportion of women who reported experiencing GBD varied between 0% in several regions in Benin, Mali, Senegal, South Africa, and Zimbabwe and 24·7% in Atacora, Benin. We identified a positive association between the proportion of women who reported experiencing GBD in a region in the past year and MMR (β 0.88, CI [0.65; 1.12]). A 1% increase in the proportion of women experiencing GBD resulted in an increase of the MMR by nearly two, meaning, an additional two more maternal deaths per 100,000 live births. This association was even more pronounced after adjusting for region-level covariates, but did not change with the inclusion of country-level covariates (β 1.95, CI [1.71; 2.19]). Conclusions The study’s findings show that the rate of self-reported GBD is associated with maternal mortality in a region, even after controlling for other factors that are known to influence maternal deaths. However, our model does not rule out endogeneity. Further research is needed to unravel causal pathways between GBD and maternal mortality.

This study quantitatively assessed the population-wide lead poisoning conditions in Kabwe, Zambia, a town with severe lead pollution. While existing data have reported concerning blood lead levels (BLLs) of residents in pollution hotspots, the data representing the entire population are lacking. Further, selection bias is a concern. Given the lack of compulsory testing schemes, BLLs have been observed from voluntary participants in blood sampling surveys, but such data can represent higher or lower BLLs than the population average because of factors simultaneously affecting participation and BLLs. To illustrate the lead poisoning conditions of the population, we expanded the focus of our surveys and then econometrically estimated the BLLs of individuals representing the population, including those not participating in blood sampling, using background geographic, demographic, and socioeconomic information. The estimated population mean BLL was 11.9 μg/dL (11.6–12.1, 95% CI), lower than existing data because of our wide focus and correction of selection bias. However, the scale of lead poisoning remained immense and 74.9% of residents had BLLs greater than 5 μg/dL, the standard reference level for lead poisoning. Our estimates provide a deeper understanding of the problem and a foundation for policy intervention designs.

Introduction. Costing evidence is essential for policy makers for priority setting and resource allocation. It is in this context that the clinical trials of ARVs and cotrimoxazole provided a costing component to provide evidence for budgeting and resource needs alongside the clinical efficacy studies. Methods. A micro based costing approach was adopted, using case record forms for maintaining patient records. Costs for fixed assets were allocated based on the paediatric space. Medication and other resource costs were costed using the WHO/MSH Drug Price Indicators as well as procurement data where these were available. Results. The costs for cotrimoxazole and ARVs are significantly different. The average costs for human resources were US$22 and US$71 for physician costs and $1.3 and $16 for nursing costs while in-patient costs were $257 and $15 for the cotrimoxazole and ARV cohorts, respectively. Mean or average costs were $870 for the cotrimoxazole cohort and $218 for the ARV. The causal factors for the significant cost differences are attributable to the higher human resource time, higher infections of opportunistic conditions, and longer and higher frequency of hospitalisations, among others.

Zambia implemented an ambitious process of health sector decentralization in the mid 1990s. This article presents an assessment of the degree of decentralization, called ‘decision space’, that was allowed to districts in Zambia, and an analysis of data on districts available at the national level to assess allocation choices made by local authorities and some indicators of the performance of the health systems under decentralization. The Zambian officials in health districts had a moderate range of choice over expenditures, user fees, contracting, targeting and governance. Their choices were quite limited over salaries and allowances and they did not have control over additional major sources of revenue, like local taxes. The study found that the formula for allocation of government funding which was based on population size and hospital beds resulted in relatively equal per capita expenditures among districts. Decentralization allowed the districts to make decisions on internal allocation of resources and on user fee levels and expenditures. General guidelines for the allocation of resources established a maximum and minimum percentage to be allocated to district offices, hospitals, health centres and communities. Districts tended to exceed the maximum for district offices, but the large urban districts and those without public district hospitals were not even reaching the minimum for hospital allocations. Wealthier and urban districts were more successful in raising revenue through user fees, although the proportion of total expenditures that came from user fees was low. An analysis of available indicators of performance, such as the utilization of health services, immunization coverage and family planning activities, found little variation during the period 1995–98 except for a decline in immunization coverage, which may have also been affected by changes in donor funding. These findings suggest that decentralization may not have had either a positive or negative impact on services.

Background Scaling up services to achieve HIV targets will require that countries optimize the use of available funding. Robust unit cost estimates are essential for the better use of resources, and information on the heterogeneity in the unit cost of delivering HIV services across facilities – both within and across countries – is critical to identifying and addressing inefficiencies. There is limited information on the unit cost of HIV prevention services in sub-Saharan Africa and information on the heterogeneity within and across countries and determinants of this variation is even more scarce. The “Optimizing the Response in Prevention: HIV Efficiency in Africa” (ORPHEA) study aims to add to the empirical body of knowledge on the cost and technical efficiency of HIV prevention services that decision makers can use to inform policy and planning. Methods/Design ORPHEA is a cross-sectional observational study conducted in 304 service delivery sites in Kenya, Rwanda, South Africa, and Zambia to assess the cost, cost structure, cost variability, and the determinants of efficiency for four HIV interventions: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC), and HIV prevention for sex workers. ORPHEA collected information at three levels (district, facility, and individual) on inputs to HIV prevention service production and their prices, outputs produced along the cascade of services, facility-level characteristics and contextual factors, district-level factors likely to influence the performance of facilities as well as the demand for HIV prevention services, and information on process quality for HTC, PMTCT, and VMMC services. Discussion ORPHEA is one of the most comprehensive studies on the cost and technical efficiency of HIV prevention interventions to date. The study applied a robust methodological design to collect comparable information to estimate the cost of HTC, PMTCT, VMMC, and sex worker prevention services in Kenya, Rwanda, South Africa, and Zambia, the level of efficiency in the current delivery of these services, and the key determinants of efficiency. The results of the study will be important to decision makers in the study countries as well as those in countries facing similar circumstances and contexts.

Background Today's uncertain HIV funding landscape threatens to slow progress towards treatment goals. Understanding the costs of antiretroviral therapy (ART) will be essential for governments to make informed policy decisions about the pace of scale-up under the 2013 WHO HIV Treatment Guidelines, which increase the number of people eligible for treatment from 17.6 million to 28.6 million. The study presented here is one of the largest of its kind and the first to describe the facility-level cost of ART in a random sample of facilities in Ethiopia, Malawi, Rwanda, South Africa and Zambia. Methods & Findings In 2010-2011, comprehensive data on one year of facility-level ART costs and patient outcomes were collected from 161 facilities, selected using stratified random sampling. Overall, facility-level ART costs were significantly lower than expected in four of the five countries, with a simple average of $208 per patient-year (ppy) across Ethiopia, Malawi, Rwanda and Zambia. Costs were higher in South Africa, at $682 ppy. This included medications, laboratory services, direct and indirect personnel, patient support, equipment and administrative services. Facilities demonstrated the ability to retain patients alive and on treatment at these costs, although outcomes for established patients (2-8% annual loss to follow-up or death) were better than outcomes for new patients in their first year of ART (77-95% alive and on treatment). Conclusions This study illustrated that the facility-level costs of ART are lower than previously understood in these five countries. While limitations must be considered, and costs will vary across countries, this suggests that expanded treatment coverage may be affordable. Further research is needed to understand investment costs of treatment scale-up, non-facility costs and opportunities for more efficient resource allocation.

In this study, we aim to quantitatively assess the population-wide exposure to lead pollution in Kabwe, Zambia. While Kabwe is known as one of the most significant cases of environmental pollution in the world, the available information does not provide a representative figure on residents’ lead poisoning conditions. To obtain a representative figure, we estimate blood lead level (BLL) of the representative sample of Kabwe by combining two datasets: BLL data collected based on residents’ voluntary participation to blood sampling and socioeconomic data collected for approximately 900, randomly chosen households that represent Kabwe population. The results show that the representative mean BLL is slightly lower than the one observed in previous studies but a few times higher than the recent standard BLL of 5μg/dL above which health risks become significant.

Improving access to maternal health services is a critical policy concern, especially in Sub-Saharan Africa (SSA) where maternal mortality rates remain very high, particularly so among the poorest segments of society. Hence, following the global call to reduce maternal mortality embedded in the Sustainable Development Goal 3, multiple interventions have been designed and implemented across SSA countries to foster progress towards Universal Health Coverage (UHC) of maternal health services, including skilled birth attendance. While evidence on the impact of these interventions on access to service use is increasing, evidence on the distributional incidence of the financial investment they entail is still limited. This paper aims to close this gap in knowledge by conducting a quasi-longitudinal benefit incidence analysis to assess equality of both public and overall health spending on maternal health services in three Sub-Saharan African countries: Burkina Faso, Malawi and Zambia. The study relied on healthcare utilization data derived from different national-level household surveys (including Demographic and Health Survey, Performance-based Financing Survey, and Zambia Household Health and Expenditure Survey) and health expenditure data derived from National Health Accounts. The findings demonstrate increasing equality in health spending over time, but also considerable persistent heterogeneity in distributional incidence across provinces/regions/districts. These findings suggest that the implementation of UHC-specific reforms targeting maternal care was effective in increasing equality in health spending, meaning that more financial resources reached the poorest segments of society, but was not yet sufficient to remove differences across provinces/regions/districts. Further research is needed to investigate sources of regional disparities and identify strategies to overcome them.