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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.

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.

Few data exist for the production or costs of health service in developing countries. Consequently, researchers and policy makers have not been able to clearly identify technical or allocative inefficiencies in the provision of care. To remedy this shortcoming, the Institute for Health Metrics and Evaluation, UNICEF, and others have collaborated on de-novo costing exercises across a dozen developing countries. This project has engaged in-country partners to survey over 2300 health facilities. These facilities range from large, referral hospitals to small clinics and pharmacies. Facility-level data are supplemented by centralised information from ministries of health and other national-level financing agents. In most countries, panel data were collected, from 2007 to 2011. Data collection and analysis is ongoing in many countries, but it is complete for a subset, including four African countries: Ghana, Kenya, Uganda, and Zambia. This work will report descriptive values of costs and provision across these countries, as well as results from country-level and cross-country production and cost functions. We particularly focus on quantifying technical inefficiencies in service provision, and on identifying how the degree of those inefficiencies has changed over time. Patterns in expenditure and levels of service provision vary across countries, and these differences are in part explained by each country's level of economic development. Personnel expenditure is more important in less-developed countries and less-sophisticated facilities, and in general levels of service provision have increased at a faster rate than either personnel counts or expenditure. These data and subsequent analyses are critically important to in-country policy makers and international donors. Undoubtedly, the demand for health service will increase in these countries along with population growth and economic wealth. To maintain (let alone improve) current service levels, policy makers must understand the sources and degrees of inefficiency in service provision, and have reliable estimates of the costs of expanding service. This study is the most comprehensive exercise conducted to date to understand these issues across countries. Bill & Melinda Gates Foundation.

The life-saving benefits of antiretroviral therapy (ART) for HIV-infected patients have been well established. However, there continues to be much debate on how best to deliver ART care. In this study, we seek to answer part of this question by examining facility-level determinants of patient outcome. We examined a nationally representative sample of health facilities providing ART in Kenya, Uganda, and Zambia. Facility-level data were collected through an extensive survey that gathered information ranging from finances and management, to services and outputs. Patient-level information was collected from a random sample of charts of patients who were receiving or had received ART. All adult patients who had been on ART between 6 and 60 months at the time of data collection, regardless of outcome, were eligible for inclusion. Descriptive statistics examining patient-level trends at ART initiation over time, as well as logistic regression and survival analyses to assess for facility-level effects on outcome, were performed. We collected data from more than 30 000 patient charts across 138 facilities. Initial findings suggest that patient outcomes are largely driven by patient-level characteristics at the time of ART initiation. Initial CD4 cell count, body-mass index, and WHO clinical staging were all predictive of 12-month and 24-month retention. Conversely, we found no consistent 12-month or 24-month retention trend with regard to facility-level ART programme characteristics such as facility type (hospital vs health clinic), location (urban vs rural), management (private vs public), funding source, number of years the facility has been in operation, leadership type (physician vs nurse), or existence of outreach programmes. These findings further support the critical need to expand ART programmes to initiate patients early in the disease process. They also suggest that many aspects of ART care could potentially be carried out safely and effectively at smaller, lower complexity facilities with less-specialised personnel. Bill & Melinda Gates Foundation.

•Despite high overall satisfaction, some users remained unsatisfied.•User satisfaction is undermined by poor quality partly defined by long waiting times.•Despite associated funding and logistical challenges, outreach is a preferred mode.•Implications of association of outreach with greater satisfaction are discussed. The main aim of this study was to assess care-giver satisfaction with vaccination services in public health facilities in Zambia, and examine its determinants. This study used data from a recent population-based household survey, conducted from May to August 2015. Respondent satisfaction with vaccination services received during the last visit was measured on a five point Likert scale ranging from 1 to 5. We used an ordered logistic regression model to analyse the significance of perceived quality of vaccination services, immunisation delivery mode and a range of individual characteristics in predicting care-giver satisfaction. Findings show that one in five care givers were unsatisfied with the vaccination services that they had received, with rural populations showing a significantly higher level of satisfaction. Poor quality of care, defined by long waiting times, poor quality of communication between health staff and care givers, long distance to vaccination sites, mode of delivery, and personal characteristics were among major factors driving care-giver satisfaction ratings. We also find that receiving a vaccination at outreach mode of delivery was associated with higher odds of greater satisfaction compared to on-facility vaccination services. The odds of satisfaction were lower for respondents living further away from a health facility, which emphasizes the importance of access in seeking vaccination services. These findings suggest that major improvements in quality of vaccination and service organisation will be needed to increase client satisfaction and service utilisation.

Background Since 2000, international funding for HIV has supported scaling up antiretroviral therapy (ART) in sub-Saharan Africa. However, such funding has stagnated for years, threatening the sustainability and reach of ART programs amid efforts to achieve universal treatment. Improving health system efficiencies, particularly at the facility level, is an increasingly critical avenue for extending limited resources for ART; nevertheless, the potential impact of increased facility efficiency on ART capacity remains largely unknown. Through the present study, we sought to quantify facility-level technical efficiency across countries, assess potential determinants of efficiency, and predict the potential for additional ART expansion. Methods Using nationally-representative facility datasets from Kenya, Uganda and Zambia, and measures adjusting for structural quality, we estimated facility-level technical efficiency using an ensemble approach that combined restricted versions of Data Envelopment Analysis and Stochastic Distance Function. We then conducted a series of bivariate and multivariate regression analyses to evaluate possible determinants of higher or lower technical efficiency. Finally, we predicted the potential for ART expansion across efficiency improvement scenarios, estimating how many additional ART visits could be accommodated if facilities with low efficiency thresholds reached those levels of efficiency. Results In each country, national averages of efficiency fell below 50 % and facility-level efficiency markedly varied. Among facilities providing ART, average efficiency scores spanned from 50 % (95 % uncertainty interval (UI), 48–62 %) in Uganda to 59 % (95 % UI, 53–67 %) in Zambia. Of the facility determinants analyzed, few were consistently associated with higher or lower technical efficiency scores, suggesting that other factors may be more strongly related to facility-level efficiency. Based on observed facility resources and an efficiency improvement scenario where all facilities providing ART reached 80 % efficiency, we predicted a 33 % potential increase in ART visits in Kenya, 62 % in Uganda, and 33 % in Zambia. Given observed resources in facilities offering ART, we estimated that 459,000 new ART patients could be seen if facilities in these countries reached 80 % efficiency, equating to a 40 % increase in new patients. Conclusions Health facilities in Kenya, Uganda, and Zambia could notably expand ART services if the efficiency with which they operate increased. Improving how facility resources are used, and not simply increasing their quantity, has the potential to substantially elevate the impact of global health investments and reduce treatment gaps for people living with HIV.

Sub-Saharan African countries have been experiencing a persistently high level of inequality in access to healthcare services. Following the global call to eliminate health inequalities worldwide, different investments in health policies towards Universal Health Coverage (UHC) have been made in many Sub-Saharan African countries. However, evidence on the distributional incidence of health spending on these recent UHC-specific reforms is still limited. This paper aimed 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 curative health services across socioeconomic groups in three Sub-Saharan African countries: Burkina Faso, Malawi and Zambia. The study relied on healthcare utilization data derived from different nation-level household surveys (including Living Condition and Monitoring Survey, Performance based Financing Survey, and Zambia Household Health and Expenditure Survey) and health expenditure data derived from National Health Accounts. The findings demonstrated increasing equality in the distributional incidence of health spending over time, but also considerable persistent heterogeneity across provinces/regions/district. Less health financing inequality was observed in Malawi than in the other two country. These findings suggest that the implementation of UHC-specific reforms was effective in increasing equality in the distributional incidence of 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 heterogeneity within countries and identify strategies to overcome it.

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.

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.