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Various investments could help countries deliver on the universal health coverage (UHC) goals set by the global community; community health is a pillar of many national strategies toward UHC. Yet despite resource mobilisation toward this end, little is known about the potential costs and value of these investments, as well as how evidence on the same would be used in related decisions. This qualitative study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries (LMICs). Through key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision making, as well as evidentiary needs related to community health data for decision making. We found that evidence use is limited at all levels, in part due to a perceived lack of high-quality, relevant evidence. This perception stems from two main areas: first, desire for local evidence that reflects the context; second, much existing economic evidence does not deal with what decision makers value when it comes to community health systems – that is, coverage and (to a lesser extent) quality. Beyond the evidence gap, there is limited capacity to assess and use the evidence. Elected officials also face political challenges to disinvestment as well as structural obstacles to evidence use, including the outsized influence of donor priorities. Evaluation data must to speak to decision maker interests and constraints more directly, alongside financiers of community health providing explicit guidance and support on the role of evidence use in decision making, empowering national decision makers. Improved data quality, increased relevance of evidence and capacity for evidence use can drive improved efficiency of financing and evidence-based policymaking.

Introduction Aid effectiveness and improving its impact is a central policy matter for donors and international organisations. Pooled funding is a mechanism, whereby donors provide financial contributions towards a common set of broad objectives by channeling finance through one instrument. The results of pooled funds as an aid mechanism are mixed, and there is limited data on both methodology for, and results of, assessment of effectiveness of pooled funding. Methods This study adapted a conceptual framework incorporating the Paris Principles of Aid Effectiveness and qualitative methods to assess the performance of the Health Transition Fund (HTF) Zimbabwe. 30 key informant interviews, and 20 focus group discussions were conducted with informants drawn from village to national level. Descriptive secondary data analysis of Demographic Health Surveys, Health Management Information Systems (HMIS) and policy reports complemented the study. Results The HTF combined the most optimal option to channel external aid to the health sector in Zimbabwe during a period of socioeconomic and political crisis. It produced results quickly and at scale and enhanced coordination and ownership at the national and subnational level. Flexibility in using the funds was a strong feature of the HTF. However, the initiative compromised on the investment in local capacity and systems, since the primary focus was on restoring essential services within a nearly collapsed healthcare system, rather than building long-term capacity. Significant changes in maternal and newborn health outcomes were observed during the HTF implementation in Zimbabwe. Conclusion A framework which can be used to assess pooled funds was adapted and applied. Future assessments could use this or another framework to provide new evidence regarding effectiveness of pool donor funds although the frameworks should be properly tested and adapted in different contexts.

Rapidly increasing healthcare costs and the growing burden of non-communicable diseases have increased the out-of-pocket (OOP) spending (63.3% of total health expenditure) in Bangladesh. This increasing OOP spending for healthcare has catastrophic economic impact on households. To reduce this burden, the Health Economics Unit (HEU) of the Ministry of Health and Family Welfare has developed the Shasthyo Surokhsha Karmasuchi (SSK) health protection scheme for the below-poverty line (BPL) population. The key actors in the scheme are HEU, contracted scheme operator and hospital. Under this scheme, each enrolled household is provided 50,000 BDT (620 USD) coverage per year for healthcare services against a government financed premium of 1000 BDT (12 USD). This initiative faces some challenges e.g., delays in scheme activities, registering the targeted population, low utilization of services, lack of motivation of the providers, and management related difficulties. It is also important to estimate the financial requirement for nationwide scale-up of this project. We aim to identify these implementation-related challenges and provide feedback to the project personnel. This is a concurrent process documentation using mixed-method approaches. It will be conducted in the rural Kalihati Upazila where the SSK is being implemented. To validate the BPL population selection process, we will estimate the positive predictive value. A community survey will be conducted to assess the knowledge of the card holders about SSK services. From the SSK information management system, numbers of different services utilized by the card holders will be retrieved. Key-informant interviews with personnel from three key actors will be conducted to understand the barriers in the implementation of the project as per plan and gather their suggestions. To estimate the project costs, all inputs to be used will be identified, quantified and valued. The nationwide scale-up cost of the project will be estimated by applying economic modeling. SSK is the first ever government initiated health protection scheme in Bangladesh. The study findings will enable decision makers to gain a better understanding of the key challenges in implementation of such scheme and provide feedback towards the successful implementation of the program.

Devolution changes the locus of power within a country from central to sub-national levels. In 2013, Kenya devolved health and other services from central government to 47 new sub-national governments (known as counties). This transition seeks to strengthen democracy and accountability, increase community participation, improve efficiency and reduce inequities. With changing responsibilities and power following devolution reforms, comes the need for priority-setting at the new county level. Priority-setting arises as a consequence of the needs and demand for healthcare resources exceeding the resources available, resulting in the need for some means of choosing between competing demands. We sought to explore the impact of devolution on priority-setting for health equity and community health services. We conducted key informant and in-depth interviews with health policymakers, health providers and politicians from 10 counties (n = 269 individuals) and 14 focus group discussions with community members based in 2 counties (n = 146 individuals). Qualitative data were analysed using the framework approach. We found Kenya's devolution reforms were driven by the need to demonstrate responsiveness to county contexts, with positive ramifications for health equity in previously neglected counties. The rapidity of the process, however, combined with limited technical capacity and guidance has meant that decision-making and prioritization have been captured and distorted for political and power interests. Less visible community health services that focus on health promotion, disease prevention and referral have been neglected within the prioritization process in favour of more tangible curative health services. The rapid transition in power carries a degree of risk of not meeting stated objectives. As Kenya moves forward, decision-makers need to address the community health gap and lay down institutional structures, processes and norms which promote health equity for all Kenyans.

International development donors and governments have strengthened their commitment and spend on research capacity strengthening (RCS) initiatives in low-and-middle-income countries (LMICs) in recent years1. RCS support in a development context is provided on the basis that greater research capacity leads to socioeconomic growth through evidence-informed policy and practice, improvements in human capital and pro-poor products/technologies2. Despite increasing investment, the evidence-base pertaining to the design, selection and evaluation of RCS interventions in LMICs is limited at present confounding informed decision-making3. There are few robust outcome or impact evaluations of RCS interventions or agreed evaluation frameworks with standardised metrics, and the body of RCS literature that is available is highly fragmented4-7. The current state of the RCS evidence-base reflects, in part, the inherent complexity of the RCS endeavour which may be characterised as a multifaceted, long-term, continuous process subject to a diverse range of influences and assumptions5. Yet it remains the case that there is not yet sufficient evidence to reliably inform which types of intervention, in which combinations, with which focus and in what proportion, are required to build research capacity effectively and sustainably in LMIC settings.

HEALTH CARE COSTS POLICIES, ECONOMICS AND OUTCOMES -- HEALTH CARE COSTS POLICIES, ECONOMICS AND OUTCOMES -- Library of Congress Cataloging-in-Publication Data -- CONTENTS -- PREFACE -- Chapter 1 INNOVATIVE ANALYTICAL METHODS FOR LONGITUDINAL MEDICAL COST DATA: TRANSLATING RESEARCH TO INFORM POLICY AND PRACTICE -- ABSTRACT -- INTRODUCTION AND PURPOSE -- LONGITUDINAL ASSESSMENT OF COST IN HEALTH CARE INTERVENTIONS -- A. Analytical Issues Commonly Encountered in the Analysis of Longitudinal Medical Cost Data -- A1. Empirical Challenges in Analyzing Medical Costs Data

Introduction Tuberculosis incidence is disproportionately high among people in poverty. Cash transfer programs have become an important strategy in Brazil fight inequalities as part of comprehensive poverty alleviation policies. This study was aimed at assessing the effect of being a beneficiary of a governmental cash transfer program on tuberculosis (TB) treatment cure rates. Methods We conducted a longitudinal database study including people ≥18 years old with confirmed incident TB in Brazil in 2015. We treated missing data with multiple imputation. Poisson regression models with robust variance were carried out to assess the effect of TB determinants on cure rates. The average effect of being beneficiary of cash transfer was estimated by propensity-score matching. Results In 2015, 25,084 women and men diagnosed as new tuberculosis case, of whom 1,714 (6.8%) were beneficiaries of a national cash transfer. Among the total population with pulmonary tuberculosis several determinants were associated with cure rates. However, among the cash transfer group, this association was vanished in males, blacks, region of residence, and people not deprived of their freedom and who smoke tobacco. The average treatment effect of cash transfers on TB cure rates, based on propensity score matching, found that being beneficiary of cash transfer improved TB cure rates by 8% [Coefficient 0.08 (95% confidence interval 0.06–0.11) in subjects with pulmonary TB]. Conclusion Our study suggests that, in Brazil, the effect of cash transfer on the outcome of TB treatment may be achieved by the indirect effect of other determinants. Also, these results suggest the direct effect of being beneficiary of cash transfer on improving TB cure rates.

"Health Economics is a required course in almost every graduate program in Health Admin, though there are health econ courses (often electives) across disciplines; for example, public health, respiratory care, pharmacy, and nursing. Because of the role economics plays in finance and policy, it can also be adopted in those courses. This book is not discipline-specific, so it covers a wide breadth."

Examines how microeconomic principles apply to health care delivery and its policies by exploring the changing nature of health care, the social and political sides of issues, and the future of health care delivery and finance as the U.S. transitions beyond the Affordable Care Act. Discusses how to analyze public policy from an economic perspective, and addresses today's policy environment and changes as well as reform alternatives. Includes special features that discuss issues in healthcare today, profile health care leaders and offer global comparisons. Appendices show how to interpret empirical results and perform economic evaluations

This paper summarizes a longer paper, written for the American Association of Health Plans. That paper extensively surveys the research on the savings due to managed care and quantifies the costs of eliminating specific managed care practices in terms of both dollars and in terms of increasing the number of uninsured consumers. This issue is of immediate policy interest because managed care has recently come under legislative and legal attack that would eliminate or hinder the various managerial actions and contractual practices that constitute its essence.

Objectives As in many low-income and middle-income countries, out-of-pocket (OOP) payments by patients or their families are a key healthcare financing mechanism in Bangladesh that leads to economic burdens for households. The objective of this study was to identify whether and to what extent socioeconomic, demographic, and behavioral factors of the population had an impact on OOP expenditures in Bangladesh. Methods A total of 12 400 patients who had paid to receive any type of healthcare services within the previous 30 days were analyzed from the Bangladesh Household Income and Expenditure Survey data, 2010. We employed regression analysis for identify factors influencing OOP health expenditures using the ordinary least square method. Results The mean total OOP healthcare expenditures was US dollar (USD) 27.66; while, the cost of medicines (USD 16.98) was the highest cost driver (61% of total OOP healthcare expenditure). In addition, this study identified age, sex, marital status, place of residence, and family wealth as significant factors associated with higher OOP healthcare expenditures. In contrary, unemployment and not receiving financial social benefits were inversely associated with OOP expenditures. Conclusions The findings of this study can help decision-makers by clarifying the determinants of OOP, discussing the mechanisms driving these determinants, and there by underscoring the need to develop policy options for building stronger financial protection mechanisms. The government should consider devoting more resources to providing free or subsidized care. In parallel with government action, the development of other prudential and sustainable risk-pooling mechanisms may help attract enthusiastic subscribers to community-based health insurance schemes.

Although oral PrEP is highly effective at preventing HIV acquisition, optimizing continuation among beneficiaries is challenging in many settings. We estimated the costs of delivering oral PrEP to populations at risk of HIV in seven clinics in Zimbabwe. Full annual economic costs of oral PrEP initiations and continuation visits were estimated from the providers' perspective for a six-clinic NGO network and one government SGBV clinic in Zimbabwe (January–December 2018). Disaggregating costs of full initiation and incremental follow-up visits enabled modeling of the impact of duration of continuation on the cost per person-year ($pPY) on PrEP. 4677 people initiated oral PrEP, averaging 2.7 follow-up visits per person. Average cost per person initiated was $238 ($183–$302 across the NGO clinics; $86 in the government facility). The full cost per initiation visit, including central and direct costs, was $178, and the incremental cost per follow-up visit, capturing only additional resources used directly in the follow up visits, was $22. The average duration of continuation was 3.0 months, generating an average $pPY of $943, ranging from $839 among adolescent girls and young women to $1219 in men. Oral PrEP delivery costs varied substantially by scale of initiations and by duration of continuation and type of clinic. Extending the average oral PrEP continuation from 2.7 to 5 visits (about 6 months) would greatly improve service efficiency, cutting the $pPY by more than half.