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BackgroundMonitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services.MethodsOur study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place.ResultsOur sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15–39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p2 = 0.018; p3 = 0.001; p4 = 0.002), and urban residency (p = 0.001).ConclusionOur findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

IntroductionTuberculosis (TB) remains an important public health challenge globally. Madagascar faces a substantial TB burden despite enhanced efforts from its national TB control programme. This necessitates innovative and context-specific TB prevention and care interventions that are both impactful and cost-effective. We evaluated the effectiveness and cost-effectiveness of a community-based mobile TB clinic intervention in a remote rural area of Madagascar, addressing specific access barriers and implementation challenges.MethodsThe analysis employed an interrupted time series analysis (ITSA) comparing the intervention to the standard national TB control programme (NTP) to assess the effectiveness of the intervention in increasing TB case detection rates. A decision tree model was used to evaluate the cost-effectiveness of the intervention from a healthcare provider perspective when compared with the NTP. The study incorporated one-way sensitivity analyses and Monte Carlo simulations with 10 000 iterations to generate the probability distribution of estimates and uncertainty ranges.ResultsThe ITSA found that the intervention cumulatively increased TB case detection 2.88-fold compared with the control group over the 27-month study period. The probability for a patient to successfully complete TB treatment in the intervention group was 97%, compared with 91% in the control group. Incremental costs per person with TB were $316. With an incremental cost-effectiveness ratio (ICER) of $25 per disability-adjusted life year averted, well below the $96 cost effectiveness threshold for Madagascar, the intervention was highly cost-effective. Importantly, the ICER remained robust throughout sensitivity analyses, reaching a maximum of $67.ConclusionThe study underscores the importance of community-based interventions for TB and calls for policymakers to prioritise and scale up such interventions, both in Madagascar and in other low-income countries with similar access-related challenges.

Antenatal care (ANC) is one of the pillars of maternal and child health programs aimed at preventing and reducing maternal and child morbidity and mortality. This study aims to identify the factors associated with ANC use, considering both health care demand and supply factors in the single analysis. We used data from the endline survey conducted to evaluate the impact of the performance-based financing (PBF) program in Burkina Faso in 2017. This study was a blocked-by-region cluster random trial using a pre-post comparison design. The sample was derived in a three-stage cluster sampling procedure. Data collection for the endline surveys included a household survey and a facility-based survey. Women of childbearing age who gave birth at least once in the past 2 years prior to this survey and residing in the study area for more than 6 months were included in this study. Multilevel statistical techniques were used to examine individual and contextual effects related to health care demand and supply simultaneously and thus measure the relative contribution of the different levels to explaining factors associated with ANC use. The working women were five times [odd ratio (OR): 5.41, 95% confidence intervals (CI) 4.36-6.70] more likely to report using ANC services than the women who were not working (OR: 5.41, 95% CI 4.36-6.70). Women living in a community with high poverty concentration were 32.0% (OR: 0.68, 95% CI 0.50-0.91) less likely to use ANC services than those in a community with low poverty concentration. Women living in a community with a medium concentration of women's modern contraceptive use were almost two times (OR: 1.88, 95% CI 1.70-2.12) more likely to use ANC services than those living in a community with a low concentration of women's modern contraceptive use. Women living in the health area where the level of ANC quality was high were three times (OR: 2.96, 95% CI 1.46-6.12) more likely to use ANC services than those in the health area where the ANC quality was low. Policies that increase the opportunity for improving the average ANC quality at the health facility (HF), the level of women's modern contraceptive use and women employment would likely be effective in increasing the frequency of use of antenatal services.

BackgroundIn low- and middle-income countries (LMICs), tuberculosis (TB) regained its status as the leading cause of death from a single infectious agent in 2023, surpassing COVID-19. Rapid and accurate diagnosis is critical, with decentralised diagnostic strategies offering a promising solution. Although decentralised diagnostic strategies have been proven cost-effective, further evidence is needed on affordability and equity in high-burden settings. This study, part of a multicentre real-world cluster-randomised controlled trial (cRCT), assessed implementation costs and out-of-pocket (OOP) expenditures across socioeconomic status (SES) groups from a societal perspective.MethodsThe TB-CAPT Core trial compared decentralised point-of-care TB testing using the Molbio Truenat platform (intervention) with the hub-and-spoke Xpert MTB/RIF Ultra model (control) in Tanzania and Mozambique. Economic data were collected as part of the trial along with asset ownership information using an equity tool. Multiple correspondence analysis was used to construct an asset index for each country. Extended cost-effectiveness analysis estimated incremental participant costs for TB diagnosis and health outcomes (number of participants who initiated treatment within seven and sixty days) across SES groups. Distributional cost-effectiveness analysis assessed facility-based diagnostic cost per treatment initiated from a societal perspective across SES groups. Regression analyses explored the intervention’s impact on direct, indirect and total costs.ResultsAverage OOP expenditures were lower in the intervention arm (US$8.82) than in the control group (US$13.61). Regression analysis confirmed a significant cost reduction. Least poor participants experienced greater cost-savings (−US$6.36 vs −US$2.93), while the poorest had a higher number of TB treatment initiations within 7 days of diagnosis (poorest vs least poor: 28 vs 8). The incremental cost-effectiveness ratio for the poorest group was US$778, whereas for the other two groups, the intervention showed higher treatment initiation (52 vs 36 for middle, 33 vs 25 for least poor) at lower costs than the standard of care.ConclusionThe intervention reduced patient costs and improved outcomes across SES groups. Decentralised TB testing with the Molbio Truenat platform is both cost-saving and more effective and cost-effective compared with a hub-and-spoke model in Mozambique and Tanzania.

Background: Burkina Faso has been implementing financing reforms towards Universal Health Coverage since 2006. Recently, the country introduced a performance-based financing program (PBF) as well as user fee removal (gratuité) policy for health services aimed at pregnant and lactating women and children under five. We aim to assess the effect of gratuité and PBF policies on facility-based out-of-pocket expenditures (OOPE) for outpatient services. Methods: Our study is a controlled pre- and post-test design using healthcare facility data from the PBF program’s impact evaluation collected in 2014 and 2017. We compared OOPE related to primary healthcare use incurred by children under five and individuals above five to assess the effect of the gratuité policy on OOPE. We further compared OOPE incurred by individuals residing in PBF districts and non-PBF districts to estimate the effect of the PBF on OOPE. Effects were estimated using difference-in-differences (DID) models, distinguishing the estimation of the probability of incurring OOPE from the estimation of the magnitude of OOPE using a generalized linear model (GLM). Results: The proportion of children under five incurring OOPE declined significantly from 90% in 2014 to 3% in 2017. Concurrently, mean OOPE also decreased. Differences in both the probability of incurring OOPE and mean OOPE between PBF and non-PBF facilities were small. Our DID estimates indicated that gratuité produced an 84% (CI -86%, -81%) reduction in the probability of incurring OOPE and reduced total OOPE by 54% (CI 63%, 42%). We detected no significant effects of PBF, either in reducing the probability of incurring OOPE or in its magnitude. Conclusions: User fee removal is an effective demand-side intervention for enhancing financial accessibility. As a supply-side intervention, PBF appears to have limited effects on reducing financial burden.

To identify factors associated with decision to enrol in a community health insurance (CHI) scheme. We conducted a population-based case-control study among 15 communities offered insurance in 2004 in rural Burkina Faso. For inclusion in the study, we selected all 154 enrolled (cases) and a random sample of 393 non-enrolled (controls) households. We used unconditional logistic regression (applying Huber-White correction to account for clustering at the community level) to explore the association between enrolment status and a set of household head, household and community characteristics. Multivariate analysis revealed that enrolment in CHI was associated with Bwaba ethnicity, higher education, higher socioeconomic status, a negative perception of the adequacy of traditional care, a higher proportion of children living within the household, greater distance from the health facility, and a lower level of socioeconomic inequality within the community, but not with household health status or previous household health service utilization. Our study provides evidence that the decision to enrol in CHI is shaped by a combination of household head, household, and community factors. Policies aimed at enhancing enrolment ought to act at all three levels. On the basis of our findings, we discuss specific policy recommendations and highlight areas for further research.

BackgroundMeasuring progress towards financial risk protection for the poorest is essential within the framework of Universal Health Coverage. The study assessed the level of out-of-pocket expenditure and factors associated with excessive out-of-pocket expenditure among the ultra-poor who had been targeted and exempted within the context of the performance-based financing intervention in Burkina Faso. Ultra-poor were selected based on a community-based approach and provided with an exemption card allowing them to access healthcare services free of charge.MethodsWe performed a descriptive analysis of the level of out-of-pocket expenditure on formal healthcare services using data from a cross-sectional study conducted in Diébougou district. Multivariate logistic regression was performed to investigate the factors related to excessive out-of-pocket expenditure among the ultra-poor. The analysis was restricted to individuals who reported formal health service utilisation for an illness-episode within the last six months. Excessive spending was defined as having expenditure greater than or equal to two times the median out-of-pocket expenditure.ResultsExemption card ownership was reported by 83.64% of the respondents. With an average of FCFA 23051.62 (USD 39.18), the ultra-poor had to supplement a significant amount of out-of-pocket expenditure to receive formal healthcare services at public health facilities which were supposed to be free. The probability of incurring excessive out-of-pocket expenditure was negatively associated with being female (β = − 2.072, p = 0.00, ME = − 0.324; p = 0.000) and having an exemption card (β = − 1.787, p = 0.025; ME = − 0.279, p = 0.014).ConclusionsUser fee exemptions are associated with reduced out-of-pocket expenditure for the ultra-poor. Our results demonstrate the importance of free care and better implementation of existing exemption policies. The ultra-poor’s elevated risk due to multi-morbidities and severity of illness need to be considered when allocating resources to better address existing inequalities and improve financial risk protection.

Background Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection. Methods The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004–06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004–2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models. Results We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase. Conclusions Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it’s essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations.

Background: Antigen-based rapid diagnostic tests (Ag-RDT) have been implemented in hospitals and nursing homes to screen for infectious individuals without symptoms suggestive of SARS-CoV-2 infections and to prevent entry into these high-risk settings. Despite their benefits for screening, the cost of large-scale implementation is largely understudied. Our study presents evidence on their implementation costs in high-risk settings. This study aimed to estimate the economic costs of implementing Ag-RDT-based screening for SARS-CoV-2 in two tertiary care hospitals (University Hospital Heidelberg - UKHD, and Charité - Universitätsmedizin Berlin) and one nursing home in Germany. Methods: We adopted a health system perspective and followed the three sequential steps to costing: identification of resources, measurement of resource consumption, and valuation of costs. Data on resource consumption were collected between October 2020 and April 2021 through various techniques and data sources. The cost estimation considered all costs along the screening algorithm including PCR confirmation tests for positive cases. We estimated the costs for the two implementation modalities observed: staff dedicated exclusively to screening and staff not dedicated exclusively to screening. Furthermore, cost estimations were performed under both observed capacity use and hypothetical capacity use assumptions (60, 80 and 100%). Results: Our study indicates that the average cost per Ag-RDT is highly dependent on the capacity use and implementation mode. Staff time and test kits are the two main cost drivers of implementing the large-scale screening programs for SARS-CoV-2 using Ag-RDTs. For hospitals, the average cost per test in UKHD was €30.12 (capacity observed); €14.56 (non-dedicated mode); €19.47, €16.37, €14.53 at 60, 80, 100% capacity respectively (dedicated mode); and at Charité €13.10 (non-dedicated mode). For the nursing home the estimated average cost per test was €15.03 (non-dedicated mode). Conclusions: The information on the estimated costs by mode of implementation and capacity use may support the planning of Ag-RDT-based covid-19 screening programs suitable for each institution. Further research is needed to cost this screening strategy for COVID-19 in other high-risk, high-income settings to reach generalizability.

Background Poor access and low contraceptive prevalence are common to many Low- and Middle-Income Countries (LMICs). Unmet need for family planning (FP), defined as the proportion of women wishing to limit or postpone child birth, but not using contraception, has been central to reproductive health efforts for decades and still remains relevant for most policy makers and FP programs in LMICs. There is still a lag in contraceptive uptake across regions resulting in high unmet need due to various socioeconomic and cultural factors. In this mixed method scoping review we analyzed quantitative, qualitative and mixed method studies to summarize those factors influencing unmet need among women in LMICs. Methods We conducted our scoping review by employing mixed method approach. We included studies applying quantitative and qualitative methods retrieved from online data bases (PubMed, JSTOR, and Google Scholar). We also reviewed the indexes of journals specific to the field of reproductive health by using a set of keywords related to unmet contraception need, and non-contraception use in LMICs. Results We retrieved 283 articles and retained 34 articles meeting our inclusion criteria. Of these, 26 were quantitative studies and 8 qualitative studies. We found unmet need for FP to range between 20 % and 58 % in most studies. Woman’s age was negatively associated with total unmet need for FP, meaning as women get older the unmet need for FP decreases. The number of children was found to be a positively associated determinant for a woman’s total unmet need. Also, woman’s level of education was negatively associated – as a woman’s education improves, her total unmet need decreases. Frequently reported reasons for non-contraception use were opposition from husband or husbands fear of infidelity, as well as woman’s fear of side effects or other health concerns related to contraceptive methods. Conclusion Factors associated with unmet need for FP and non-contraception use were common across different LMIC settings. This suggests that women in LMICs face similar barriers to FP and that it is still necessary for reproductive health programs to identify FP interventions that more specifically tackle unmet need.