An implementation evaluation of a policy aiming to improve financial access to maternal health care in Djibo district, Burkina Faso

BACKGROUND

To bring down its high maternal mortality ratio, Burkina Faso adopted a national health policy in 2007 that designed to boost the assisted delivery rate and improving quality of emergency obstetrical and neonatal care. The cost of transportation from health centres to district hospitals is paid by the policy. The worst-off are exempted from all fees.

METHODS

The objectives of this paper are to analyze perceptions of this policy by health workers, assess how this health policy was implemented at the district level, identify difficulties faced during implementation, and highlight interactional factors that have an influence on the implementation process. A multiple site case study was conducted at 6 health centres in the district of Djibo in Burkina Faso. The following sources of data were used: 1) district documents (n = 23); 2) key interviews with district health managers (n = 10), health workers (n = 16), traditional birth attendants (n = 7), and community management committees (n = 11); 3) non-participant observations in health centres; 4) focus groups in communities (n = 62); 5) a feedback session on the findings with 20 health staff members.

RESULTS

All the activities were implemented as planned except for completely subsidizing the worst-off, and some activities such as surveys for patients and the quality assurance service team aiming to improve quality of care. District health managers and health workers perceived difficulties in implementing this policy because of the lack of clarity on some topics in the guidelines. Entering the data into an electronic database and the long delay in reimbursing transportation costs were the principal challenges perceived by implementers. Interactional factors such as relations between providers and patients and between health workers and communities were raised. These factors have an influence on the implementation process. Strained relations between the groups involved may reduce the effectiveness of the policy.

CONCLUSIONS

Implementation analysis in the context of improving financial access to health care in African countries is still scarce, especially at the micro level. The strained relations of the providers with patients and the communities may have an influence on the implementation process and on the effects of this health policy. Therefore, power relations between actors of the health system and the community should be taken into consideration. More studies are needed to better understand the influence of power relations on the implementation process in low-income countries.

Reimbursement for EMS response, medical care, and transport

The National Association of EMS Physicians (NAEMSP) believes that emergency medical services (EMS) response, care, and transport should be fairly reimbursed based on the prudent layperson standard. This paper is the official position of the NAEMSP. Key words: EMS; reimbursement; medical care; position statement; NAEMSP.

Quantifying the reduction in nonmedical costs after the introduction of a rural county hospital in Ecuador

OBJECTIVE

This study attempts to quantify the impact of the introduction of local second-level health services on nonmedical costs (NMCs) for residents of the rural Ecuadorian county of La Maná.

METHODS

NMCs for patients accessing second-level health care were assessed by using a quasi-experimental pre- and postintervention study design. In 2007, before local second-level health care services existed, and then in 2008, after the introduction of second-level health care services in the form of a county hospital, 508 patients from the county who sought second-level health care were interviewed.

RESULTS

Mean NMCs per patient per illness episode were US$ 93.58 before the county hospital opened and US$ 12.62 after it opened. This difference was largely due to reductions in transport costs (US$ 50.01 vs. US$ 4.28) and food costs (US$ 25.38 vs. US$ 7.28) (P < 0.001 for each category).

CONCLUSIONS

NMCs can be decreased sevenfold with the introduction of a county hospital in a rural province previously lacking second-level health care. Introduction of rural second-level health care reduces financial barriers and thus may increase access to these health services for poorer patients in rural communities.

Peripatetic intravenous service for metabolic bone disease: case study in patient centred-care for new NHS

OBJECTIVE

To develop a 'close to patient' peripatetic intravenous service (PIVS) for delivery of specialist osteoporosis care in a community setting without increasing cost and with a reduced carbon footprint.

RESEARCH DESIGN AND METHODS

Cost and feasibility of a PIVS for intravenous (i.v.) bisphosphonate treatment were modelled using UK National Health Service costings and then tested in the field for 1 year. Average patient mileage to peripatetic sites was compared with mileage travelled if treated at the base hospital (current practice). The method of travel to hospital (current practice) or peripatetic sites (new study) was ascertained together with patients' preference for the new or the current system. Peripatetic sites were researched and those with suitable facilities selected. Data for fuel consumption were based on a usage of 1 litre per 14.5 km.

MAIN OUTCOME MEASURES

The main outcome measure was cost comparison between hospital and peripatetic services. Others included patient satisfaction, miles saved, method of travel to the clinic and changes in CO(2) emissions.

RESULTS

Cost per patient, including drugs, lies between pound557 and pound622 annually for 1000 and 500 patients, respectively which is cost-neutral compared with hospital attendance. PIVS was rated more convenient by 98% of patients. Hospital transport was significantly reduced and the total monthly saving of 2000 miles has reduced CO(2) emission by 6072 kg p.a. No medical emergency occurred in 410 infusions.

CONCLUSIONS

PIVS is cost neutral compared with a conventional service, leads to a better patient experience, a significant cutback in hospital transport costs and a reduction of the NHS carbon footprint. However not all drugs may be suitable for this service: the area served was rural with large distances and poor public transport and mileage savings may not accrue in urban areas. Insurance was not included in the calculation of costs.

Economic aspects of mandibular third molar surgery

OBJECTIVE

The aim of this study was to make estimates from a dental care and societal perspective on costs of mandibular third molar surgery.

MATERIAL AND METHODS

A total of 64 patients were recruited from three Swedish oral and maxillofacial specialist clinics. Calculations were made prospectively on utilization of labor time, specific medical services and materials, and standardized utilization of other direct costs. Indirect costs were identified from patient surveys.

RESULTS

The base case average direct cost of surgery was 217 Euro. Adding the patient's average cost due to absence from work and transportation of 333 Euro increased overall costs to 550 Euro per patient. About 86% of the patients reported some absence following surgery.

CONCLUSIONS

The indirect costs were on average higher than the direct costs, i.e. the patient's loss of time caused higher costs than the intervention per se. Appropriate indications for mandibular third molar removal can minimize the risks of complications and individual or societal costs.

Medicaid's medical transportation assurance: origins, evolution, current trends, and implications for health reform

This policy brief examines Medicaid's assurance of medical transportation in the context of medically necessary but non-emergency health care. Reviewing the origins and evolution of the assurance and presenting the results of a 2009 survey of state Medicaid programs, the results of this analysis underscore Medicaid's unique capacity to not only finance medically necessary health care but also the services and supports that enable access to health care by low income persons since Medicaid covers non-emergency medical transportation. This ability to both finance health care and enable its use moves to the forefront as Congress considers whether to assist low income persons in health reform through Medicaid expansions or via subsidies for traditional health insurance, which typically does not provide comparable transportation coverage.

Evaluating the effects of providing financial incentives to tuberculosis patients and health providers in China

SETTING

A project was implemented in 50 low-income counties of Shanxi, where transport incentives were provided to poor patients for their first visit for tuberculosis (TB) diagnosis as well as for referral and supervision incentives for doctors.

OBJECTIVE

To evaluate the effects of providing incentives on TB case detection and treatment.

METHODS

A group of 51 control counties in Shanxi comparable to the intervention counties was selected. Routine TB reporting was reviewed at baseline (January-September 2004) and during the project period (January-September 2005) in both groups. A patient survey was conducted in two counties in each group, with interviews of 119 new smear-positive patients treated during the intervention.

RESULTS

Patients who received travel incentives had an annual individual income similar to those who did not. The notification rates of new smear-positive cases improved in both groups; however, improvement was less marked in the intervention group (70%) than in the control group (99%). Travel incentives did not reduce patient and doctor delays in the intervention group compared with the control group (P > 0.05).

CONCLUSION

Providing incentives was not effective in improving TB control. There are two possible reasons for this: the poor were not well-targeted due to a lack of operational tools, and more influential health systems issues were not addressed.

Continuous positive airway pressure therapy for infants with respiratory distress in non tertiary care centers: a randomized, controlled trial

OBJECTIVE

Our objective was to determine whether continuous positive airway pressure therapy would safely reduce the need for up-transfer of infants with respiratory distress from nontertiary centers.

METHODS

We randomly assigned 300 infants at >30 weeks of gestation with respiratory distress to receive either Hudson prong bubble continuous positive airway pressure therapy or headbox oxygen treatment (standard care). The primary end point was "up-transfer or treatment failure." Secondary end points included death, length of nursery stay, time receiving oxygen therapy, cost of care, and other measures of morbidity.

RESULTS

Of 151 infants who received continuous positive airway pressure therapy, 35 either were up-transferred or experienced treatment failure, as did 60 of the 149 infants given headbox oxygen treatment. There was no difference in the length of stay or the duration of oxygen treatment. For every 6 infants treated with continuous positive airway pressure therapy, there was an estimated cost saving of $10,000. Pneumothorax was identified for 14 infants in the continuous positive airway pressure group and 5 in the headbox group. There was no difference in any other measure of morbidity or death.

CONCLUSIONS

Hudson prong bubble continuous positive airway pressure therapy reduces the need for up-transfer of infants with respiratory distress in nontertiary centers. There is a clinically relevant but not statistically significant increase in the risk of pneumothorax. There are significant benefits associated with continuous positive airway pressure use in larger nontertiary centers.

Financial analysis of acetaminophen suicide in a teen girl

There is no doubt that prevention and primary care treatment is less costly than emergency room efforts and tertiary care to save someone's life. Preventive health care is the cornerstone of any health care system designed to reduce costs and human suffering (American Nurses Association, 1997). Unfortunately, emergency room and intensive care nurses frequently care for critically ill children and adults who suffer from conditions that might have been prevented. This case study presents the financial breakdown of the costs at each level of care for an 18-year-old college student who suffers terrible consequences of an acetaminophen overdose.

[Health care costs of acute myocardial infarction in Hungary, 2003-2005]

BACKGROUND

The morbidity of acute myocardial infarction (AMI) is remarkable in Hungary, therefore understanding the disease burden more accurately is inevitable.

AIM

We assessed the hospitalized AMI patient's burden on the financer both in active and chronic hospital care as well as outpatient visits and we estimated the size of indirect social costs.

METHODS

We assessed the active and chronic hospital care costs of 'new' AMI patients having the event in May 2003. The costs were assessed in the subsequent 12 and 24 months to the event in the population over 25 with the morbidity from the database of the National Health Insurance Fund Administration (NHIFA). Data were collected by gender and age (age groups 25-44, 45-64, 65 and over). Costs of GPs, specialist visits, transportation and productivity losses were taken into account as other costs.

RESULTS

Average health insurance costs of AMI's active hospital care in the first 12 months are generally higher in females as in males; 476.3 thousand HUF vs 391.1 thousand HUF (65 and over), 429.1 thousand HUF vs 389.4 thousand HUF (45-64) and 229.5 thousand HUF vs 240.6 thousand HUF (25-44). The burden in the chronic care is 15-40 thousand HUF per patient in the first year, which is similar to the active care costs in the 13-24th months after the AMI (22-54 thousand HUF).

CONCLUSION

NHIFA was estimated to spend 4.4 billion HUF on direct health care on behalf of the nearly 12 thousand annual AMI patients in the first 12 months, 3.6 billion HUF on the active and 370 million on the chronic hospital care. Avoiding one AMI could save 345-565 thousand HUF (depending on gender and age) direct health care cost in the first 12 months. In our estimation the annual indirect costs of AMI exceed 840 million HUF (177 829 HUF/patient) in the working age group.

Reverse transport of children from a tertiary pediatric hospital

INTRODUCTION

The purpose of this study was to determine the epidemiology and resources used and to study the potential savings of pediatric reverse transport patients.

METHODS

A case control study was performed with patients undergoing a reverse or outbound transport from a large, pediatric hospital. Twenty-five children undergoing reverse transport were compared with matched controls. Lengths of stay and costs were compared between the reverse transport and matched control patients.

RESULTS

Fifty-two percent of the reverse transport patients returned home, whereas 32% went home for end-of-life care and 16% went to other facilities. The average reverse transport was more than 400 miles and cost $6,064. The reverse transport of these patients did not save pediatric intensive care unit (PICU) days but did result in a shorter hospital stay compared with the matched controls (10 vs. 19 days, P = .03). Decreased utilization of bed days came from less use of intermediate care unit resources.

CONCLUSIONS

Pediatric patients undergo reverse transports for a variety of reasons, often for end-of-life care. The ability to reverse transport pediatric patients may not save PICU bed days but may offer pediatric tertiary care hospitals a means to provide more intermediate care bed availability.

Does distance affect utilization of substance abuse and mental health services in the presence of transportation services?

Long travel times have been identified as a significant barrier to accessing mental health and other critical services. This study examines whether distance to treatment was a barrier to receiving outpatient mental health and substance abuse care for HIV-positive persons when transportation was provided. Data from a cohort of HIV-positive persons who participated in a year-long substance abuse and mental health treatment programme were examined longitudinally. Transportation, which included buses, taxis, and mileage reimbursement for private transportation, was provided free of charge for participants who needed this assistance. Nearly three-quarters (74%) of participants utilized the transportation services. No statistically significant differences in retention in, or utilization of, the mental health and substance abuse treatment programme were identified by distance to the treatment site. This analysis demonstrated that increased distance to care did not decrease utilization of the treatment programme when transportation was provided to the client when necessary. These results provide preliminary evidence that distance to substance abuse and mental health services need not be a barrier to care for HIV-positive individuals when transportation is provided. Such options may need to be considered when trying to treat geographically dispersed individuals so that efficiencies in treatment can be attained.

Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport

Background

A study was conducted among newly registered HIV-positive tuberculosis (TB) patients systematically offered anti-retroviral treatment (ART) in a district hospital in rural Malawi in order to a) determine the acceptance of ART b) conduct a geographic mapping of those placed on ART and c) examine the association between “cost of transport” and ART acceptance.

Methodology/Principal Findings

A retrospective cross-sectional analysis was performed on routine program data for the period of February 2003 to July 2004. Standardized registers and patient cards were used to gather data. The place of residence was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient's residence. Of 1,290 newly registered TB patients, 1,003(78%) underwent HIV-testing of whom 770 (77%) were HIV-positive. 742 of these individuals (pulmonary TB = 607; extra-pulmonary TB = 135) were considered eligible for ART of whom only 101(13.6%) accepted ART. Cost of transport to the hospital ART site was significantly associated with ART acceptance and there was a linear trend in association between cost and ART acceptance (X² for trend = 25.4, P<0.001). Individuals who had to pay 50 Malawi Kwacha (1 United States Dollar = 100 Malawi Kwacha, MW) or less for a one-way trip to the Thyolo hospital were four times more likely to accept ART than those who had to pay over 100 MW (Adjusted Odds ratio = 4.0, 95% confidence interval: 2.0–8.1, P<0.001).

Conclusions/Significance

ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital based ART site. Decentralizing the ART offer from the hospital to health centers that are closer to home communities would be an essential step towards reducing the overall cost and burden of travel.

After hours healthcare for older patients in New Zealand--barriers to accessing care

AIM

To explore older people's attitudes and their perceptions of barriers when seeking medical care after hours.

METHOD

In-depth interviews and a focus group of older people were conducted and key informants were interviewed. The data was analysed using qualitative techniques.

RESULTS

Reluctance to be a nuisance, transport problems, cost, lack of information, and reluctance to see an unfamiliar doctor are among the barriers described by older people.

CONCLUSIONS

There were transport, cost, and social barriers to older people obtaining after hours medical care.