The impact of user fees on health services utilization and infectious disease diagnoses in Neno District, Malawi: a longitudinal, quasi-experimental study

Background

User fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare. We examined the effects of the introduction and removal of user fees on outpatient attendances and new diagnoses of HIV, malaria, and tuberculosis in Neno District, Malawi where user fees were re-instated at three of 13 health centres in 2013 and subsequently removed at one of these in 2015.

Methods

We conducted two analyses. Firstly, an unadjusted comparison of outpatient visits and new diagnoses over three periods between July 2012 and October 2015: during the period with no user fees, at the re-introduction of user fees at four centres, and after the removal of user fees at one centre. Secondly, we estimated a linear model of the effect of user fees on the outcome of interest that controlled for unobserved health centre effects, monthly effects, and a linear time trend.

Results

The introduction of user fees was associated with a change in total attendances of −68 % [95 % CI: −89 %, −12 %], similar reductions were observed for new malaria and HIV diagnoses. The removal of user fees was associated with an increase in total attendances of 352 % [213 %, 554 %] with similar increases for malaria diagnoses. The results were not sensitive to control group or model specification.

Conclusions

User fees for outpatient healthcare services present a barrier to patients accessing healthcare and reduce detection of serious infectious diseases.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1856-x) contains supplementary material, which is available to authorized users.

The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study

OBJECTIVE

To estimate the effect of the provision of a one-to-one nurse-to-patient ratio on mortality rates in neonatal intensive care units.

DESIGN

A population-based analysis of operational clinical data using an instrumental variable method.

SETTING

National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing, and Clinical Outcomes Project.

PARTICIPANTS

43 tertiary-level neonatal units observed monthly over the period January 2008 to December 2012.

INTERVENTION

Proportion of neonatal intensive care days or proportion of intensive care admissions for which one-to-one nursing was provided.

OUTCOMES

Monthly in-hospital intensive care mortality rate.

RESULTS

Over the study period, the provision of one-to-one nursing in tertiary neonatal units declined from a median of 9.1% of intensive care days in 2008 to 5.9% in 2012. A 10 percentage point decrease in the proportion of intensive care days on which one-to-one nursing was provided was associated with an increase in the in-hospital mortality rate of 0.6 (95% CI 1.2 to 0.0) deaths per 100 infants receiving neonatal intensive care per month compared with a median monthly mortality rate of 4.5 deaths per 100 infants per month. The results remained robust to sensitivity analyses that varied the estimation sample of units, the choice of instrumental variables, unit classification and the selection of control variables.

CONCLUSIONS

Our study suggests that decreases in the provision of one-to-one nursing in tertiary-level neonatal intensive care units increase the in-hospital mortality rate.

The effects of designation and volume of neonatal care on mortality and morbidity outcomes of very preterm infants in England: retrospective population-based cohort study

OBJECTIVE

To examine the effects of designation and volume of neonatal care at the hospital of birth on mortality and morbidity outcomes in very preterm infants in a managed clinical network setting.

DESIGN

A retrospective, population-based analysis of operational clinical data using adjusted logistic regression and instrumental variables (IV) analyses.

SETTING

165 National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing and Clinical Outcomes Project.

PARTICIPANTS

20 554 infants born at <33 weeks completed gestation (17 995 born at 27-32 weeks; 2559 born at <27 weeks), admitted to neonatal care and either discharged or died, over the period 1 January 2009-31 December 2011.

INTERVENTION

Tertiary designation or high-volume neonatal care at the hospital of birth.

OUTCOMES

Neonatal mortality, any in-hospital mortality, surgery for necrotising enterocolitis, surgery for retinopathy of prematurity, bronchopulmonary dysplasia and postmenstrual age at discharge.

RESULTS

Infants born at <33 weeks gestation and admitted to a high-volume neonatal unit at the hospital of birth were at reduced odds of neonatal mortality (IV regression odds ratio (OR) 0.70, 95% CI 0.53 to 0.92) and any in-hospital mortality (IV regression OR 0.68, 95% CI 0.54 to 0.85). The effect of volume on any in-hospital mortality was most acute among infants born at <27 weeks gestation (IV regression OR 0.51, 95% CI 0.33 to 0.79). A negative association between tertiary-level unit designation and mortality was also observed with adjusted logistic regression for infants born at <27 weeks gestation.

CONCLUSIONS

High-volume neonatal care provided at the hospital of birth may protect against in-hospital mortality in very preterm infants. Future developments of neonatal services should promote delivery of very preterm infants at hospitals with high-volume neonatal units.

Development of a push-pull ventilation system to control solder fume

Hand soldering using rosin core solder wire is common in the electronics industry and several studies have implicated the aerosol produced when rosin flux is heated in causing respiratory sensitisation. Control of solder fume is generally achieved using local exhaust hoods, simple blowers with a filter or low-volume high-velocity (LVHV) ventilation systems. None of these provide an ideal control system and so a push-pull ventilation design was developed as an alternative. Laboratory tests of the system's capture efficiency were carried out using nitrous oxide tracer gas. Capture efficiency was generally greater than 90% with the push airflow operating. However, without the push airflow, capture efficiency decreased sharply with increasing distance from the exhaust hood (between 38 and 58% at 420 mm from the front of the exhaust hood with the same exhaust airflow used by the push-pull system). The push-pull system was found to be relatively insensitive to obstructions placed in the path of the air flow or the influence of cross draughts. The system was tested in five electronics factories and the effectiveness was compared to their existing ventilation systems. Where only a small amount of soldering was carried out both the in-house and push-pull systems seemed to provide adequate control of inhalation exposure to rosin-based solder flux fume measured as total resin acids. However, the push-pull system provided more consistent control than the existing ventilation systems when larger quantities of solder were used. In these situations the mean personal exposure level was reduced to below the UK Maximum Exposure Limit (MEL) of 0.05 mg/m(3) 8-h time weighted average in most instances. The corresponding mean personal exposure level with the in-house systems in operation was about three to four times the long-term MEL. Interpretation of these data is complicated because of high background contribution to exposure from poorly controlled soldering operations elsewhere in the factories. However, this study suggests that the in-house systems were relatively inefficient.