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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Theme:
Programme and
Abstract Book
The Role of Health Economics and Policy Research.
6th AfHEA Biennial Scientic Conference
Towards Resilient
Health Systems in
Africa
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The Role of Health Economics
and Policy Research.
6th AfHEA Biennial Scientic
Conference
Published by AfHEA © 2022
Cover Page: Dot Scale
Compilation of the programme
and abstracts: Elizabeth Adote
and Daniel Achala
The scientic contents of the
abstracts are entirely the
responsibility of their authors.
The opinions expressed do not
necessarily reect the positions
of AfHEA.
For further information, kindly
write to:
info@afhea.org
Visit the AfHEA web site for
updates on its activities:
www.afhea.org
The 6th AfHEA Scientic
Conference is organized in
partnerships with the
and
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Table of Contents
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How have adjustments in public nancial management and strategic purchasing contributed to COVID-19 health sector response? Lessons for building back
better. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Public Financial Management And Covid-19 Health Response: Key Lessons For System Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Public Financial Management And Covid-19 Health Response In South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Adjustments In Purchasing Arrangements As Part Of The Covid-19 Health Sector Response: A Global Synthesis . . . . . . . . . . . . . . . . . . . . . . .29
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Investing in Health systems Post COVID . . . . . . . . . . . . . . . . . . . . . . . . . 32
COVID-19, Government Healthcare Investment in EAC and SADC Regions: The Role of Social Capital in Public Support for Healthcare Investment . . . . . .32
Strengthening Public Financial Management Systems . . . . . . . . . . . . . . . . . . 37
Improving Public Financial Management (Pfm) To Support The Health Objectives Of Nigeria’s Federal Ministry Of Health (Fmoh) . . . . . . . . . . . . . .39
Strengthening Financial Management Systems In Tertiary Hospitals: A Case Study Of A West African National Hospital . . . . . . . . . . . . . . . . . . 40
Strengthening Public Financial Management For More Efcient Health Financing Reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
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Decision Models And Quality Of Care . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Developing The Eq-5d-5l Value Set For Uganda Using The ‘Lite’ Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
The Financial Architecture Of Vector Borne Diseases In Burkina Faso . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Application Of Decision Analytical Models To Diabetes In Low- And Middle-Income Countries: A Systematic Review . . . . . . . . . . . . . . . . . . . . 46
Optimizing Health Investments Through Health Benets Package Modelling: A Case Study Of The Nigerian Ward Health System . . . . . . . . . . . . . 47
Peer Effects And Quality: Neighbouring Facilities Responsiveness To Quality Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Economic Evaluation, Its Role And Possible Impact In The Public Health Emergency Management Of Disease Outbreaks And Response In Africa . . . . . 50
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Impact of COVID on Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Impact of Covid-19 on public healthcare access in Madagascar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Impact Of Covid-19 On Use Of Maternal Healthcare Services In Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Impact Of Covid-19 Lockdown On The Economy Of A Low-Resource Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Healthcare Utilization In Ghana And Associated Factors During The Covid-19 Pandemic – A Cross-Sectional Public Survey . . . . . . . . . . . . . . . . . .56
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Decentralization: Friend Or Foe To Public Financial Management In Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Implications Of Decentralization For Public Financial Management In Health: Lessons From Burkina Faso, Kenya, Indonesia, Mozambique, Nigeria, The
Philippines, Tanzania, And Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Local Governments Readiness For Devolution Of Health Financing: The Case Of Communes In Burkina Faso . . . . . . . . . . . . . . . . . . . . . . . .59
What Are The Implications Of Decentralization And Public Financial Management Reforms For Delivery Of Services At Primary Care Level? Findings From
Mozambique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Tanzania’s Experience Implementing Direct Facility Financing In The Health Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62
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How Can Country Public Finance Management Systems Enable Better Response To Future Epidemics: What Lessons Have African Countries Learned From
Covid-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Predictability And Timelines Of Health Care Resources From The National Level To Health Facilities In Kenya: What Are The Implications For Emergency
Response? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
Budget Structure And Emergency Response: Leveraging Uganda’s Transition To Program Based Budgeting To Improve Preparedness And Response . . . .65
Effect of Public Finance Management (PFM) System on COVID-19 Response and Preparedness in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . 66
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Accountability For Covid-19 Extra-Budgetary Funds In Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
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Strengthening Community Health Care Systems . . . . . . . . . . . . . . . . . . . . . 69
Willingness to enrol and pay for Community Based Health Insurance, decision motives and associated factors among rural households in Enugu state,
Southeast Nigeria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Efciency in Utilization of the Resources Allocated to Lower Level Health Facilities in Uganda: A Case Study of Health Centre IVs . . . . . . . . . . . . . . 70
Level and Determinants of County Health System Technical Efciency in Kenya: Two Stage Data Envelopment Analysis . . . . . . . . . . . . . . . . . . . 71
Developing the community health system in Benin: an analysis of the 2020-2024 National Community Health Policy . . . . . . . . . . . . . . . . . . . .72
Primary Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Primary Health Care versus Universal Health Coverage: Towards Achieving “Health for All”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
Marketplace aspect of Primary Health Centres in Nigeria and its implication for health care delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
Level and correlates of willingness to pay for rapid COVID-19 testing delivered through private-retail pharmacies in Kenya. . . . . . . . . . . . . . . . . . .76
Role of Actor Networks in Primary Health Care Implementation in Low-And Middle-Income Countries: A Scoping Review . . . . . . . . . . . . . . . . . .77
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Maternal, Adolescent and Child Health Interventions 1 . . . . . . . . . . . . . . . . . . 79
Burden of childhood and adolescence Asthma in Nigeria: Disability Adjusted Life Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Extension of Seasonal Malaria Chemoprevention to children aged over ve: a quasi-experimental evaluation of effectiveness and externality effects . . . . 80
Understanding the impact of the COVID-19 pandemic on maternal and child health services in Nigeria: lessons learnt for future pandemics . . . . . . . . . 81
Multilevel governance collaboration aspirations and reality: insights from a maternal neonatal and child health Policy process in Nigeria . . . . . . . . . . 82
Decomposing socioeconomic inequalities in antenatal care utilisation in 12 Southern African Development Community countries . . . . . . . . . . . . . 83
Estimating the economic burden of typhoid in children and adults in Blantyre, Malawi: a costing cohort study . . . . . . . . . . . . . . . . . . . . . . . 83
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Health Financing Poster Session 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Challenges to Informal Sector Enrollment on the Lagos State Health Scheme: Findings from a rapid assessment . . . . . . . . . . . . . . . . . . . . . 85
Pursing National Health Insurance in the (Post ) Covid-19 Era: Policy Implications and options for UHC advancement in Uganda . . . . . . . . . . . . . . 86
Integration of Family Planning Services into Social Health Insurance Scheme: Experience from Lagos, Nigeria . . . . . . . . . . . . . . . . . . . . . . . 87
From project mode to routine business: Uganda’s efforts to institutionalize results-based nancing in government purchasing of primary health care services
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
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Innovative approaches to health system strengthening Poster Session 2 . . . . . . . . . . 90
Innovating critical interpretive approaches to synthesis literature on factors inuencing cancer treatment service access in Ghana . . . . . . . . . . . . . 90
Weighted Goal Programming Approach for Solving Budgetary HIV Treatment in Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Informing product development for health benet in Africa: a generalisable approach and application to a leishmaniasis vaccine . . . . . . . . . . . . . .92
COVID-19 Vaccine Health Technology Assessment in African Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93
Health Technology Assessment of Covid-19 Vaccines in Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Health Technology Assessment of COVID-19 Vaccines in Ethiopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
The Impact and Economic Evaluation of COVID-19 Vaccine Strategies in Different Population and Outbreak Contexts among African Countries . . . . . . .95
Collecting Evidence to Inform COVID-19 Vaccine Procurement Decisions: A Toolkit for African Countries . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Health Technology Assessment of COVID-19 Vaccines in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
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The Impact of COVID-19 on Health Financing in Low- and Middle-Income Countries: Findings from Burkina Faso, Kenya, and Uganda. . . . . . . . . . . . 99
The Impact Of Covid-19 On Health Financing In Kenya, Burkina Faso, And Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
PFM reforms and COVID-19 management in the health sector: the case of Burkina Faso . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
The Impact Of Covid-19 On Health Financing In Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Purchasing arrangements and adjustments adopted to nance Uganda’s COVID-19 response: Insights from local governments and the frontlines . . . . . 103
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The Use Of Data And Evidence For Decision Making In Hta: Adopting An Evidence Deliberative Process As A Mechanism For Strengthening Decision Making
In Health Technology Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
The Use Of Evidence And The Hta Process In Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Evidence and a decision-making process in Tanzania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Evidence and HTA Methods For Medicines Selection In South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Integrating EDP’s and HTA in the revision of Zambia’s HBP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
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Impact Of Health Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Expanding State-level Fiscal Space in an era of health sector reform: Evidence from Abia and Osun states of Nigeria . . . . . . . . . . . . . . . . . . . . 109
Catastrophic health care spending and impoverishment in Tanzania: evidence from the recent national household survey . . . . . . . . . . . . . . . . 110
Socio-Economic Inequalities and Determinants of Catastrophic Health Expenditure in Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
The impact of out-of-pocket expenditures on missed appointments at HIV care and treatment centers in Northern Tanzania . . . . . . . . . . . . . . . 112
Catastrophic health expenditure amongst people living with HIV seeking care at two tertiary care and treatment centers in North Tanzania . . . . . . . . 113
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Impact of COVID on Health Services_FR . . . . . . . . . . . . . . . . . . . . . . . . .114
Impact of a free care policy on the utilization of health services during an Ebola outbreak in the Democratic Republic of Congo: an interrupted time-series
analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Factors Associated with People’s Knowledge of Covid-19 in Abidjan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Economic impact of the Covid-19 pandemic in Africa: the case of Côte d’Ivoire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Contributions to the response against the coronavirus in Burkina Faso, dynamics towards a resilient system: results of a living mapping . . . . . . . . . . 117
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Pricing and Procurement Practices Poster Session 3 . . . . . . . . . . . . . . . . . . .119
Price Structure Of Medicines In Côte D’ivoire And Price Comparison In The Countries Of The West African Monetary And Economic Union . . . . . . . . . 119
Determinants for pricing induced abortion services in licensed health facilities in Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Identifying inefcient pharmaceutical procurement practices at the tertiary level of care in Nigeria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Compliance Indicators of COVID-19 Prevention and Vaccines Hesitancy in Kenya: A Random-Effects Endogenous Probit Model . . . . . . . . . . . . . . 122
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Resource Allocation Poster Session 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Allocating resources to support universal health coverage: development of a geographical funding formula in Malawi . . . . . . . . . . . . . . . . . . . 123
Health nancing policy reforms for universal health coverage in Eastern, Central and Southern Africa (ECSA) – Health Community: Any lessons learned on how
to nance COVID-19 pandemic from domestic resources? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Health Sector Budgetary Allocations and their Implications on Health Service Delivery and UHC in Uganda . . . . . . . . . . . . . . . . . . . . . . . . 125
The Contrat unique in Lualaba Province: Analysis of the implementation of a resources allocation’s policy at the decentralized level in the Democratic Republic
of the Congo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
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Building Back Better Health Systems: Planning to Invest in the Health Workforce in Africa 128
The State of the Health Workforce in Africa: Where Do We Stand in the Middle of a Pandemic? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Planning for Needs-based Investments in the Health Workforce: Framework, Tools, and Insights from an Empirical Application in Ghana . . . . . . . . . 130
Investing in the Current and Future Health Workforce: An Analysis of Fiscal Space in Eastern and Southern Africa . . . . . . . . . . . . . . . . . . . . . 131
Making A Case For Health Workforce Investments In Africa Using Health Labour Market Analysis (Hlma): Lessons From 16 Countries . . . . . . . . . . . . 132
Building Back Better Health Systems In Africa Post Covid-19: Innovative Approaches For Enhancing Health Workforce Performance For Health Security And
Universal Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Operationalizing Efciency: Opportunities, Constraints, And Necessities . . . . . . . . . 135
Cross-Programmatic Efciency Analysis To Support Covid-19 Response In Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Cross-Programmatic Inefciencies And Implications For Covid-19 Rollout In Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Sustainability of HIV, TB and Malaria Services in Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Constraints And Opportunities To Address Inefciency In AFRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Synthesis Of Findings From Cross-Programmatic Efciency Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
� � � � � � � � � � � � � � � � � � � � � � � � � � � 141
Strategic Health Purchasing Progress In Sub-Saharan Africa And Adjustments Needed For
Health Financing Systems To Become More Resilient To Pandemics . . . . . . . . . . . .141
Strengths and Weaknesses of Purchasing in the ve major health nancing schemes in Burkina Faso . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Strengths And Weaknesses Of Purchasing In Rwanda To Advance Towards Universal Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Strategic Health Purchasing In Nigeria: Investigating Governance And Institutional Capacities Within The Formal Sector Social Health Insurance Programme
And Tax-Funded Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Strategic Health Purchasing In Nigeria: Investigating Governance And Institutional Capacities Within The Formal Sector Social Health Insurance Programme
And Tax-Funded Health Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Assessment Of Strategic Healthcare Purchasing Arrangements In Three Public Insurance Schemes In Tanzania . . . . . . . . . . . . . . . . . . . . . . 146
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UHC Policy Processes and Reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Examining the Efciency of Health Systems in Sub-Saharan Africa: Monitoring Progress towards Universal Health Coverage . . . . . . . . . . . . . . . . 147
Progress in the face of cuts: a qualitative Nigerian case study of maintaining progress towards universal health coverage after losing donor assistances . . 148
Situating donor transition in the context Universal Health Coverage (UHC) and Health System Resilience: Lessons from cross programmatic efciency
assessment in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Socioeconomic inequity in the screening and treatment of hypertension in Kenya: evidence from a national survey . . . . . . . . . . . . . . . . . . . . 150
Improving UHC processes in sub-Saharan Africa: what can the process documentation methodological approach bring in? . . . . . . . . . . . . . . . . 151
� � � � � � � � � � � � � � � � � � � � � � � � � � 153
Strategic purchasing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Tracking Progress Towards Strategic Purchasing for Healthcare in Nigeria: A Case Study of the Niger State Healthcare System . . . . . . . . . . . . . . . 153
The contribution of The Nigeria State Health Investment Project to building resilient health systems: Lessons from Ten years of Results Based Financing
implementation in Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Strategic Health Purchasing for Universal Health Coverage in Benin: A Critical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Sustainable Health Financing in Africa: Expenditure and Revenue Projections and Fiscal Space Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . 156
A critical analysis of recent history of African countries’ state of health nancing, with special attention on strategic purchasing & priority setting . . . . . 157
� � � � � � � � � � � � � � � � � � � � � � � � � � 159
Impact of COVID on Health Services_FR 2 . . . . . . . . . . . . . . . . . . . . . . . 159
Non-linear effects of health crises on economic activity in 27 African countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Role of civil society and contribution of community actors to ght COVID-19 in Burkina Faso . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Impact of the COVID-19 pandemic and response on the utilization of health services in public facilities during the rst wave in Kinshasa, the Democratic
Republic of the Congo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Investment Cases For Transformative Results In The Decade Of Action: Case Studies In Sub-
Saharan Africa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Botswana: Investment Case of the Transformative Results by 2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
South Sudan: Investment Case of the Transformative Results by 2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Namibia: Investment Case of the Transformative Results by 2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
� � � � � � � � � � � � � � � � � � � � � � � � � � � 167
Scaling up Surgery in sub-Saharan Africa: Exploring the Fundamental Economics and
Dynamic Complexities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Financing of Surgery and Anaesthesia in Sub-Saharan Africa: A Scoping Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Economic Costs of Providing District- and Regional- Level Surgeries in Tanzania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Surgical Capacity, Productivity and Efciency at the District Level in Sub-Saharan Africa: A Three-country Study . . . . . . . . . . . . . . . . . . . . . . 169
Options for Surgical Mentoring: Lessons from Zambia Based on Stakeholder Consultation and Systems Science . . . . . . . . . . . . . . . . . . . . . . 170
� � � � � � � � � � � � � � � � � � � � � � � � � � 171
Cost and Cost-effecteness of health interventions 1 . . . . . . . . . . . . . . . . . . . .171
Evaluating the direct medical costs associated with prematurity during the initial hospitalization in Rwanda: a prevalence based cost of illness study . . . 171
Modelling The Cost-Effectiveness Of Essential And Advanced Critical Care For Covid-19 Patients In Kenya . . . . . . . . . . . . . . . . . . . . . . . . . 173
Cost and Cost-effectiveness of Pediatric Oncology Unit in Ethiopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Projecting the cost of introducing typhoid conjugate vaccine (TCV) in the national immunization program in Malawi using a standardized costing framework
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
� � � � � � � � � � � � � � � � � � � � � � � � � � 177
Cost and Cost-effectiness of health interventions 2 . . . . . . . . . . . . . . . . . . . 177
Direct and Indirect Costs of Non-surgical Treatment for Acute Tonsillitis in Children in Southeast Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . 177
Cost for Diabetes and Hypertension Management in Health Facilities in Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Examining the Unit Costs of COVID-19 Vaccine Delivery in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Cost-effectiveness analysis of the extension of seasonal malaria chemoprevention (SMC) to children aged 5-9 years in a health district, Mali: Methods and
preliminary ndings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Examining the cost-effectiveness of personal protective equipment for formal healthcare workers in Kenya during the COVID-19 pandemic . . . . . . . . 181
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � 182
Investment in Training Health workforce Poster Session 5 . . . . . . . . . . . . . . . . 182
Training strategic leaders for the Nigerian Health Sector: A needs assessment study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Enhancing the Capacity of Surveillance actors in Transforming SORMAS Data into Evidence informed decision making on COVID-19 Response in Nigeria . 183
Building back better health systems includes access to quality healthcare for older persons in cash grant-selected communities – Implications for Ghana’s
healthcare system in achieving UHC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
How can health planners decide what to invest in health systems strengthening? Review of existing literature and priorities for future research. . . . . . . 185
Evaluation results from a Training of Trainers in economic evaluation for public health decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . 186
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � 188
Determinants of Health Poster Session 6 . . . . . . . . . . . . . . . . . . . . . . . . 188
COVID-19: Impact on Dental Care Utilization among Students of University of Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Socio-Economic Burden Of Covid-19 On Households In Blantyre, Malawi: Evidence From A Cross-Sectional Survey . . . . . . . . . . . . . . . . . . . . . 189
An empirical analysis of the determinants of Human Development in Africa: A gender approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Impact of road trafc injuries on household economic welfare in Sub-saharan Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
� � � � � � � � � � � � � � � � � � � � � � � � � � � 192
Integrating Care For Maternal Health And Non-Communicable Disease: Design, Costs, And
Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Reducing Indirect Causes Of Maternal Mortality And Morbidity In Nigeria: Experiences From Implementing An Integrated Model Of Care . . . . . . . . . 193
Leveraging Digital Health Technology For Integration Of Care: Design, Early Results, Costs, And Critical Considerations . . . . . . . . . . . . . . . . . . 194
Costs, Potential Long-Term Savings, And Sustainability Of An Integrated Model Of Maternal Health And Non-Communicable Disease Package Of Care Services
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
� � � � � � � � � � � � � � � � � � � � � � � � � � � 197
Economics of Neglected Tropical Skin Diseases: Findings from Liberia, Ghana, and Ethiopia
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Economic Impact Of Neglected Tropical Diseases Of The Skin On Households In Ghana: A Qualitative Analysis
Jacob Novignon, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
“Even if he gets hungry or thirsty, he’ll endure all just for the sake of treatment cost”: A qualitative analysis of the economic and nancial impact of cutaneous
leishmaniasis and leprosy on households in rural Ethiopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
A Conceptual Model For Assessing The Cost-Effectiveness Of Integrated Case Finding And Management Strategies For Neglected Tropical Skin Diseases . 200
Financing Care For Severe Stigmatizing Skin Diseases In Liberia: Challenges And Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
� � � � � � � � � � � � � � � � � � � � � � � � � � �
Implementation and economics of diagnosis for communicable and non-communicable
diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Dening An Infectious Disease Diagnosis Continuum From R&D To Utilisation: Perspectives On Data Gaps . . . . . . . . . . . . . . . . . . . . . . . . 204
Experiences with the diagnosis of Female Genital Schistosomiasis and Cervical Cancer in Madagascar . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Evaluation Of A Mass Screening And Treatment Program For Hepatitis C Virus In Rwanda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Community Engagement Initiative To Improve Access To Cardiovascular Diseases Diagnostic Services In Senegal . . . . . . . . . . . . . . . . . . . . . 207
The Potential Of Hta To Inform Decisions On New Health Technologies In Low-Income Settings. The Case Of Malawi . . . . . . . . . . . . . . . . . . . . 208
� � � � � � � � � � � � � � � � � � � � � � � � � � �
Harnessing Knowledge For Health Systems – The Role Of Co-Producing Knowledge . . . 210
� � � � � � � � � � � � � � � � � � � � � � � � � � 211
Vaccine Economics: Equity, Distribution And Financing 1 . . . . . . . . . . . . . . . . . 211
Stakeholders’ perspectives on internal accountability within a sub-national immunization programme: a qualitative study in Enugu State, South-East Nigeria
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Factors Inuencing Uptake of Astrazeneca Vaccine among Hospital Nurses in the Upper East Region of Ghana: A cross-sectional survey . . . . . . . . . . 213
Uptake and Coverage of Covid-19 Vaccination in Nigeria: Lessons from Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
� � � � � � � � � � � � � � � � � � � � � � � � � � � � 216
Vaccine Economics: Equity, Distribution And Financing 2 . . . . . . . . . . . . . . . . 216
Estimating the cost of COVID-19 vaccine deployment and introduction in Ghana using the CVIC Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Determining the prevalence of missed opportunities for vaccination and its associated factors in a South Western Nigerian State: A policy imperative for
Immunization Agenda 2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
An assessment of the quality of routine immunization data in health facilities in Lagos State, South West Nigeria. . . . . . . . . . . . . . . . . . . . . . 218
A Comparative Analysis of the Risk and Odds of Deaths related to Covid-19 Infection and Vaccinations, Cameroon . . . . . . . . . . . . . . . . . . . . . 219
Assessing the value of investing in COVID-19 vaccination in Low- and Middle-income countries: A Cost-Effectiveness Analysis . . . . . . . . . . . . . . . 220
� � � � � � � � � � � � � � � � � � � � � � � � � � � � 222
Malaria, NCDs and HIV Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Reducing health shock, household savings and investments in education: Case of malaria in Mali. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Systematic review of cost and cost-effectiveness of Seasonal Malaria Chemoprevention (SMC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Estimating the Economic Burden of HIV/AIDS on Inpatients and Outpatients Living with HIV/AIDS at the Nkambe District Hospital-Cameroon. . . . . . . 224
Cost of Introducing and Delivering RTS,S/AS01 Malaria Vaccine Within the Malaria Vaccine Implementation Program . . . . . . . . . . . . . . . . . . . 225
Double Burden of Diabetes Mellitus and Hypertension- Assessment of Direct and Indirect Cost of Treatment and their Catastrophic Health Expenditure in
Enugu State, South-East Nigeria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � 228
Maternal Health Interventions Poster Session 7 . . . . . . . . . . . . . . . . . . . . . 228
Malaria prophylaxis stock out impact on maternal and birth outcomes in Zimbabwe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Reproductive health life course and multisectoral approach for improving maternal and child health and survival. . . . . . . . . . . . . . . . . . . . . . 228
The Effect of Maternity Waiting Homes on Health Care Utilisation and Maternal and Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
The effect of fee exemption policies on postpartum health outcomes; evidence from the free maternal health care policy in Ghana. . . . . . . . . . . . . 230
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � 232
Health Sector Perceptions and Demand for Services: Poster Session 8 . . . . . . . . . . 232
Economic burden of diabetes Mellitus in Kenya: The cost of illness analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Health system responses and capacities for COVID-19 in Nigeria: a scoping review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Examining Health Sector Stakeholder Perceptions on the Efciency of County Health Systems in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . 234
The relationship between healthcare ownership and the demand for health services in Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
When the law is ambiguous: ethical dilemmas of accessing second-trimester abortion services during the COVID-19 pandemic in Ghana . . . . . . . . . 236
� � � � � � � � � � � � � � � � � � � � � � � � � � � 238
Covid-19 Impact And Response: In Country Experiences From Multiple Countries . . . . 238
COVID-19 impact on HIV COVID-19 on HIV nancing in Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
The impact of COVID-19 on health systems and lessons for future emergency preparedness: a qualitative study in Kenya . . . . . . . . . . . . . . . . . . 239
Social Assistance In Ethiopia During Covid-19: A Time-To-Event Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
COVID-19 Vaccine Country Readiness Assessment: Results From A Multi-Country Survey And Bottleneck Analysis . . . . . . . . . . . . . . . . . . . . . 241
� � � � � � � � � � � � � � � � � � � � � � � � � � � 243
The Coaching Approach: Building Capacity for Sustainable Health Systems Change . . . 243
Designing and Facilitating Effective Change Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � 247
Health Insurance And Willingness To Pay . . . . . . . . . . . . . . . . . . . . . . . . 247
Supporting the development of a health benets package in Uganda: a constrained optimisation framework . . . . . . . . . . . . . . . . . . . . . . . 247
Inequality in household willingness to pay for national Social Health Insurance Scheme in Zambia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Is Paying for Performance Brings Incremental Effect on Health Vertical Programs? An analysis based on geographical display of a case-control study on HIV/
AIDS in Mozambique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Adverse selection in health insurance markets: Evidence from South Africa using panel data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Regaining policy attention for a capitation payment reform within the National Health Insurance Scheme of Ghana: A prospective policy analysis . . . . . 251
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � 253
Evaluation Of Health Financing Systems . . . . . . . . . . . . . . . . . . . . . . . . 253
Operational and structural factors inuencing enrollment in community-based health insurance schemes: an observational study using 12 waves of
nationwide panel data from Senegal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Electronic Claims Processing and Efciency: the Case of the Ghana National Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
An economic evaluation of health insurance coverage for children affected with Burkitt lymphoma in Ghana . . . . . . . . . . . . . . . . . . . . . . . 255
Assessing the Role of Social Protection in Making Health and Health Financing Systems in Africa More Resilient To Pandemics: A Scoping Literature Review
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � 258
Maternal, Adolescent And Child Health Interventions_FR . . . . . . . . . . . . . . . . 258
Public nancial management and health in Sub-Saharan Africa : evidence from a quantitative review over 2005-2018. . . . . . . . . . . . . . . . . . . . 258
Perception of Covid-19 and Behaviours of Pregnant Women in the Bamako District (Mali) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Determinants of health care renunciation among women in Côte d’Ivoire: the case of the district of Abobo Anonkoi-3 . . . . . . . . . . . . . . . . . . . 259
Adolescents sexual and reproductive health: Identication of priority interventions in Senegal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Economics of Adolescent Sexual and Reproductive Health Interventions in Ghana: A Situational Analysis . . . . . . . . . . . . . . . . . . . . . . . . . 261
Adolescent Sexual and Reproductive Health in Senegal: Analysis of Promising or Effective Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . 262
� � � � � � � � � � � � � � � � � � � � � � � � � � � 264
Towards Building Back Better Health Systems: Why Health Systems Efciency Matters . 264
The State And Drivers Of Health Systems Efciency In Africa: A Systematic Review And Meta-Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Measuring Technical Efciency Of Health Systems In The African Region: A Two-Stage Data Envelopment Analysis With Tobit Regression . . . . . . . . . 265
Situating Donor Transition in the Path to Universal Health Coverage (UHC): Lessons from across programmatic efciency assessment in Kenya . . . . . . 266
� � � � � � � � � � � � � � � � � � � � � � � � � � � 268
Are Low- And Middle-Income Countries Prepared For Transitions Away From Donor
Financing For Health? Evidence From Ghana And Nigeria . . . . . . . . . . . . . . . . 268
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Transitioning from donor aid for health: perspectives of national stakeholders and evidence from a Discrete Choices Experiment (DCE) in Ghana . . . . . 268
Who benets from the Expanded Programme on Immunization (EPI) in Ghana: evidence from benet incidence analysis . . . . . . . . . . . . . . . . . 270
Is Nigeria On Course To Achieve Universal Health Coverage In The Context Of Its Epidemiological And Financing Transition? A Knowledge, Capacity And Policy
Gap Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Enhanced monitoring for Routine Immunization (RI) nancing in Nigeria: A transition strategy towards full self-nancing for RI . . . . . . . . . . . . . . 271
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � 273
Political Economic Dynamics In The Health Sector . . . . . . . . . . . . . . . . . . . 273
The Impact of Politics on Healthcare Seeking Behaviors: The Case of Covid-19 in Northwest Region of Cameroon. . . . . . . . . . . . . . . . . . . . . . 273
Political Prioritisation for Performance-Based Financing at the County Level in Kenya: 2015 to 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
A review of corruption and accountability issues in Nigeria’s COVID-19 response: Implications for health systems governance . . . . . . . . . . . . . . . 275
International Aid coordination between theory and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
The policy dynamics of COVID-19 vaccination in Ghana: A political priority framework approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
� � � � � � � � � � � � � � � � � � � � � � � � � � � � 278
Building Resilient Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Health nancing as a key pillar to accelerate Universal Health Coverage: the case of resilient health systems in Nigeria . . . . . . . . . . . . . . . . . . . 278
Local government coordination of responses to COVID-19 in the context of the national response in Ghana . . . . . . . . . . . . . . . . . . . . . . . . 279
Are own-source revenues an option for primary health facilities to sustain operations during the COVID-19 pandemic? Findings from Makueni County in
Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Examining the social and economic impact of COVID-19 pandemic on Internally Displaced Persons & Host Communities in Nigeria - working to build
resilience amongst the most vulnerable populations in the face of future pandemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Strengthening donor support for capacity strengthening - A systems analysis of global health aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
� � � � � � � � � � � � � � � � � � � � � � � � � � � � 284
Building Back Better Health systems . . . . . . . . . . . . . . . . . . . . . . . . . 284
An Enshrined Business Mindset and the Commitment to Make Every Effort Count: Governmental Public Health Messaging During the Covid-19 Pandemic in
Rwanda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Examining Uganda’s COVID-19 funding mechanism, response and purchasing for a resilient health system: Reections from sub-national governments and
the frontlines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Examining the Resilience of the Mental Health System, Access and Delivery of Mental Health Services in Ghana . . . . . . . . . . . . . . . . . . . . . . 285
Building a Resilient Health System for Handling Epidemics in Nigeria: The Health system strengthening and health emergency funding gaps . . . . . . . 286
Multi-sectoral collaboration (Public and Private Sector) for the delivery of Quality Healthcare Services in the Context of COVID-19 . . . . . . . . . . . . . 288
� � � � � � � � � � � � � � � � � � � � � � � � � � � �
Innovations To Improve Health Systems . . . . . . . . . . . . . . . . . . . . . . . . 290
The Role of Innovative Service Delivery Models in Improving Equity in Ghana - Implementation Research on Primary Care Provider Networks . . . . . . . 290
Practitioner treatment variation: A South African spinal pathology case study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
How Kampala rapidly deployed a new health information system to support pandemic surveillance and response in Uganda’s largest urban area . . . . . 292
Necessity Drove Public-Private Collaboration in the COVID-19 Pandemic: Uganda’s multi-sectoral approach to the COVID-19 response . . . . . . . . . . . 293
Effects of insurance tariff design on oxygen supply in public hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Control of Covid-19 in the DRC: Analysis of the main control measures taken during three waves from March 2020 to August 2021 . . . . . . . . . . . . . 295
� � � � � � � � � � � � � � � � � � � � � � � � � � � � 297
Engaging Stakeholders To Use Evidence For Policy Making . . . . . . . . . . . . . . . 297
Engaging Stakeholders in Nigeria to identify gaps and develop strategies for improving evidence use in health policy. . . . . . . . . . . . . . . . . . . . 297
Measurement and decomposition of inequity in access to Essential Health Services in the context of Universal Health Coverage in the African Region . . . 298
Data to support decisions: what is the quality of economic evaluations and their data sources for non-communicable diseases conducted in Sub-Saharan
Africa? A cross-sectional analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
COVID-19 and income-related mental health inequality in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
� � � � � � � � � � � � � � � � � � � � � � � � � � � �
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Uhc Policy Processes And Reforms_FR . . . . . . . . . . . . . . . . . . . . . . . . . 302
Equity and nancial risks protection in access to health care for all in Côte d’Ivoire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Antenatal care utilization in Côte d’Ivoire from 2010 to 2020 and fee exemption policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Health nancing in South Kivu province in Democratic Republic of Congo: evidences from operational research. . . . . . . . . . . . . . . . . . . . . . 304
Magnitude and determinants of catastrophic out-of-pocket payments for health care in Burkina Faso . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
AfHEA 2022 Scientic Conference:
Program at a Glance
Strategic Health Purchasing Skills Building Workshop - Organized by Strategic Purchasing Africa Resource Center (SPARC)
Scientic Writing for Early-Career Researchers in Health Systems and Policy - Organized by AfHEA and WHO-AFRO
Effectively using Science Communications Tools and Methods in Promoting Research Workshop - Organized by African
Health Observatory (AHOP) and The Conversation Africa
Ofcial Opening Ceremony
Session title: Building back better health systems: the role of innovation, multi-sectoral approaches and global nancial
architecture in building resilient health systems in Africa
How have
adjustments in public
nancial management
and strategic purchasing
contributed to COVID-19
health sector response?
Lessons for building back
better
Investing in Health
systems Post COVID
Impact of COVID on
Health Services
Strengthening Public
Financial Management
Systems
Decision Models and
Quality of Care
Decentralization:
friend or foe to public
nancial management in
health?
How can country
public nance management
systems enable a better
response to future
epidemics: What lessons
have African countries
learned from COVID-19?
Primary Health Care Maternal, Adolescent
and Child Health
Interventions_1
Strengthening
Community Health Systems
COVID-19 Vaccine Health Technology Assessment in African Countries
_Poster
Session 1
_Poster
Session 2
The Impact
of COVID-19 on Health
Financing in Low- and
Middle-Income Countries:
Findings from Burkina Faso,
Kenya, and Uganda
The use of data
and evidence for decision
making in HTA: Adopting
an evidence deliberative
process as a mechanism
for strengthening
decision making in Health
Technology Assessment.
Impact of Health
Expenditures
Impact of COVID on
Health Services_FR
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Building Back Better
Health Systems: Planning to
Invest in the Health Workforce
in Africa
Operationalizing
efciency: opportunities,
constraints, and necessities
Strategic health
purchasing in sub-Saharan
Africa and adjustments
needed for nancing systems
to become more resilient to
pandemics
Lessons from six countries in West and Central Africa on health system responses to Covid 19 for strengthening future national and
sub-regional health security responsiveness
_Poster Session 3
_Poster
Session 4
Investment cases for
Transformative Results in the
Decade of Action: Case studies
in Sub-Saharan Africa
Scaling up Surgery in
sub-Saharan Africa: Exploring
the Fundamental Economics
and Dynamic Complexities
Impact of COVID on
Health Services_FR2
Strategic Purchasing
UHC Policy Processes
and Reforms
Integrating care
for Maternal Health and
Non-Communicable
Disease: design, costs, and
sustainability
Economics of
Neglected Tropical Skin
Diseases: Findings from
Liberia, Ghana, and Ethiopia
Implementation
and economics of diagnosis
for communicable and non-
communicable diseases
Harnessing
knowledge for health systems
- the role of co-producing
knowledge
Cost and Cost-
Effectiveness of Health
Interventions_1
Cost and Cost-
Effectiveness of Health
Interventions_2
Accelerating towards universal access to sexual and reproductive health and rights (SRHR) in the Decade of Action
_Poster
Session 5
_
Poster Session 6
COVID-19 impact
and response: in-country
experiences from multiple
countries
The Coaching
Approach: Building Capacity
for Sustainable Health
Systems Change
Vaccine economics:
equity, distribution and
nancing_1
Vaccine economics:
equity, distribution and
nancing_2
Malaria, NCDs and HIV
research
_Poster Session
7
_
Poster Session 8
Towards Building
Back Better Health Systems:
Why Health Systems
Efciency Matters
Are low- and middle-
income countries prepared for
transitions away from donor
nancing for health? Evidence
from Ghana and Nigeria
Evaluation of Health
Financing systems
Health Insurance and
Willingness to pay
Maternal, Adolescent
and Child Health
Interventions_FR
Building Back Better
Health Systems
Building Resilient Health
Systems
Engaging stakeholders
to use evidence for policy
making
Political economic
dynamics in the health sector
UHC Policy Processes
and Reforms_FR
Innovations to improve
health systems
Organized session
Oral session
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Abstracts
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, WHO, Geneva, Switzerland, , National
Treasury, South Africa, South Africa, Dr. Inke Mathauer, PhD., WHO, Genève, Switzerland,
Aaron Asibi Abuosi, University of Ghana Business School, Ghana, Danielle Serebro, CABRI,
South Africa.
The COVID-19 crisis has exposed systemic public nancial management (PFM) bottlenecks in
health spending. It has forced countries to adapt their PFM systems to provide greater nancial
exibility and to tailor accountability systems to respond to this unprecedented crisis. Similarly,
countries had to recongure their purchasing arrangements to respond to new and different
demands for services. PFM and purchasing arrangements are closely related calling for a joint
focus for research and policy advice.
The session will share global and country perspective on countries’ PFM and strategic
purchasing aspects of the health response to COVID-19. It will discuss barriers and enablers
for an effective response, key adjustments that were introduced in countries to facilitate the
health sector response, and lessons for how to rebuild and strengthen PFM systems and
strategic purchasing arrangements to make them more responsive to future pandemics and
capable to sustain efforts towards UHC.
The rst presentation by Hélène Barroy, Sr Public Finance Expert of the WHO, will present key
lessons on needed PFM adjustments emerging from the crisis, building on a WHO survey
conducted in 180 countries in 2020. It will be illustrated by a presentation on South Africa,
delivered by Jonatan Daven, Economist, at the National Treasury, South Africa, to reect
on recent adjustments made to health budgeting and spending modalities to facilitate an
effective budgetary response to COVID-19, balancing exibility and accountability in health
spending in South Africa.
The third presentation by Inke Mathauer, Sr Health Financing Specialist of the WHO,
will discuss reconguration of purchasing arrangements to provide COVID-19 related
health services, as well as to continue provision of non-COVID-19 health services. A
country presentation on Ghana, from Aaron Abuosi, Associate Professor Health Policy and
Management, University of Ghana Business School, will follow to reect on adjustments made
to the benet package, provider payment and contracting mechanisms over the past two
years in Ghana.
A discussant, Danielle Serebro from CABRI, will join the end of the session to share concluding
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
remarks, building on extensive work conducted on the nancing of COVID-19 and COVID-19
vaccine roll-out in the region.
, WHO, Geneva, Switzerland
Public Financial Management (PFM) systems, which refers to the institutions, policies and
processes that govern the use of public funds are core to good health sector and pandemic
response management. A strong PFM system can ensure higher and more predictable budget
allocations, reduced fragmentation in revenue streams and funding ows, timely budget
execution, and better nancial accountability and transparency. During a pandemic, PFM
systems are tested in many ways, as was demonstrated during previous health emergencies
such as Ebola and SARs, and in the current COVID-19 crisis. Challenges commonly faced
by countries relate to: (i) estimating and formulating additional budgetary provisions, (ii)
making sure that funds are available for service delivery units and are disbursed efciently
while maintaining due regards for control, (iii) ensuring public funds deployed for emergency
response are tracked and accounted for in a transparent way. In this Rapid Review, the authors
document how countries have used existing PFM modalities or rened their regular practices
to enable a rapid budgetary response to COVID-19. The main ndings are organized around the
stages of a budget cycle.
Key
Our main conclusion is that countries that had already strengthened their PFM systems in
line with global good practices were able to respond faster to COVID-19 public funding needs.
We highlight examples of these practices such as program budgeting, exible virement rules,
legally mandated budget adjustments and the adoption of supplementary budgets, effective
inter-governmental transfer mechanisms. Countries that have traditional and rigid input-
based budgeting found it harder to move fast for COVID-19 fund deployment, although some
new practices were adopted by countries to bring in exibilities into input-based budgeting
by grouping budget provisions for COVID-19 into a single envelope. Emergency regulations
also allowed to simplify and accelerate spending modalities in some countries towards the
“frontlines”, by fast-tracking spending authorization processes, accelerating disbursement
of funds, and providing advance payments to purchasers and/or providers. Countries with
stringent input-based budgeting and weak PFM systems had to resort to other mechanisms –
creating off-budget Extra Budgetary Funds to pool and deploy resources. These Funds (since
they operate outside budgeting rules) can further fragment health nancing budget pools
and are not subject to stringent budget reporting and accountability standards. Attention
should be more on re-thinking regular PFM systems than sustaining new extra-budgetary and
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
parallel mechanisms. Moving forward countries are encouraged to build on those lessons to
design future PFM systems for health.
, National Treasury, South Africa, South Africa
Like in many other countries, the COVID-19 pandemic was an unprecedented shock to South
Africa as a society, but also to its public nances. Despite an already constrained pre-pandemic
scal position, a relief package of R500 billion (approx. $33 billion, around 10% of GDP) was
announced. This presentation aims to provide an overview of the PFM mechanisms used in
South Africa’s COVID-19 response and reect on how well they worked, the lessons learnt as
well as some of the challenges experienced.
Key
South Africa has a range of mechanisms to respond to emergencies and other extraordinary
events in its PFM framework, several of which were used in the COVID-19 response. Some
of these mechanisms are specically designed for emergencies, whereas others were more
routine budget mechanisms that were applied or adapted for the COVID-19 response. These
included: A special adjustment budget; Virements within budget votes; Provincial disaster
relief grant; Provisions for emergency allocations in the PFMA; In-year authorisation of
spending announced in budget speech; Emergency procurement provisions and Introducing
COVID-19 specic categories in basic accounting system. Key lessons learnt from the South
African experience include the following. The uncertainty surrounding the pandemic has
required considerable exibility and it was useful to have a wide range of mechanisms available
to fund the COVID-19 response. Different mechanisms proved benecial for different purposes
and in different phases of the response. Mechanisms that allow for rapidly augmenting
allocations in-year were particularly valuable when funding needs are difcult to project,
for example when budgeting for the COVID-19 vaccine rollout. Robust existing expenditure
reporting systems with additional categories for recording COVID-19 expenditure assisted
in continuously evaluating budget allocations but is dependent on consistent and uniform
use by departments. In addition to these mechanisms, programme budgeting, which has
been routinely used across government for at least two decades, gave departments exibility
to reprioritise funds for COVID-19 within and between budget programmes. Relaxation of
procurement rules, while well-intended and possibly required to accelerate procurement of
critical and scarce goods, also carries risk of abuse and corruption.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Dr. Inke Mathauer, PhD, WHO, Genève, Switzerland
COVID-19 continues to have a tremendous impact on health systems, with countries around
the world having recongured health service provision in order to meet the changing needs
of their population. Importantly, purchasing arrangements play a key role in facilitating and
supporting the adjustments in the provision of personal health services that are required
due to the pandemic, for both COVID-19 and non-COVID-19 health services. Country health
nancing policymakers have taken action to adjust their purchasing arrangements. Critical
purchasing actions include: expanding benets and infoinforming public with clear simple,
messages; adjusting payment methods and rates to new service delivery arrangements and
ensuring continuity in funding ows to health care providers; using private sector capacities
where needed; and establishing governance arrangements for accelerated decision-making
and set clear reporting standards. This presentation summarises how countries have
adjusted their purchasing arrangements to respond to COVID-10, explores what impact
these adjustments have had on the health system and for UHC progress, whilst also outlining
challenges. It concludes with lessons for building back better. The presentation is based on a
survey with a focus on African countries, a rapid document review, and various country case
studies from the African and other regions.
Key
The most common strategies purchasers used to cope with increased funding needs were
the reallocation of existing funds and creating greater exibility in the use of funds. It was also
reported that some purchasers had to get into decit nancing. The majority of the countries
expanded their benet package to include testing, hospitalisation and medication, with
various countries also including teleconsultation and home-based care. Another frequent
measure introduced by purchasers were nancial incentives to motivate health staff working
under difcult circumstances. Moreover, providing payments or incentives to increase
intensive care unit bed capacity was indicated in about a third of the countries. However,
one big challenge found across a number of countries is the gap between design and
implementation of purchasing adjustments, due to capacity constraints as well as different
interpretation of new rules. A key lesson is that strategic purchasing modalities need to be in
place to enable rapid adaptation to the context of a pandemic crisis.
Aaron Asibi Abuosi, University of Ghana Business School
Page 17
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
In responding to the COVID-19 related health needs in Ghana, some adjustments were made
in the purchasing arrangements as part of the service provision recongurations. The purpose
of this paper is to share ndings from a study that assessed Ghana’s adjustments made in
purchasing arrangements as part of the COVID-19 health sector response and analyse its
impacts on the health system and health nancing system as well as on UHC objectives. The
study focuses on the following research questions:
• How effective have adjustments to purchasing arrangements been in supporting the
COVID-19 health response?
• Do these modications make purchasing more strategic?
• What have been the implementation challenges of these adjustments in purchasing?
• Which modications and innovations should remain in the future?
• What is needed to “build back better”?
A mixed-method study was conducted, including a desk review and key informant interviews
based on purposive sampling techniques. The key informants included policy makers from
the Ministry of Health, Ghana Health Service and the National Health Insurance Agency,
representatives of health facilities as well as patient representatives. For the quantitative
aspect, we obtained claims data from COVID-19 claims in 2020 from hospitals for review which
we analysed by means of descriptive statistics.
The MOH Ghana introduced several changes in the purchasing arrangements: the benet
package was expanded, by including testing, isolation and hospitalisation at no costs for the
Ghanaian public; medicines and protective equipment were provided directly to hospitals by
government and donors. However, additional supplies were needed by hospitals and claims
submitted to government for reimbursement. The number of facilities designated for isolation
purposes as well as to provide testing were increased through an accelerated accreditation
process. While demand for non-COVID-19 health services slightly decreased, this was not
substantial due to relatively low numbers of COVID-19 cases. Initial results suggest that these
changes have been decisive to ensure access of people to critical COVID-19 health services.
However, the information management system remained a challenge in inuencing resource
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
allocation to and monitoring health providers. A key lesson emerging is that there is need for
comprehensive stakeholder involvement to discuss strategic purchasing for effective epidemic
response.
Page 19
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University College Dublin, Ireland
The COVID-19 pandemic has injected a new dynamism into the East African Community (EAC)
and the Southern African Development Community (SADC) Member States, to invest in their
healthcare systems to curb the spread and mitigate the overall, lasting impact of the COVID-19
pandemic on their health sectors. Whereas previously, most countries’ alleged commitment to
nance public healthcare produced inadequate levels of support and weak implementation,
the advent of COVID-19 has made EAC and SADC Member States cognisant of the need to
earmark sufcient nancial resources to health and to the building of a much more resilient
healthcare system.
This paper reports on the rst empirical analysis of the causal relationship between social
capital, measured by membership in voluntary associations, in determining public attitudes
toward governments in 15 countries belonging to two regional economic communities - the
EAC and the SADC prioritising investment in healthcare. The analysis draws on the 2014 - 2015
Round 6 surveys based on national probability samples conducted by the Afrobarometer.
Logistic regression results show that social capital is strongly and positively correlated with
public opinion toward governments prioritising investment in public healthcare. The odds
that the rst priority is healthcare investment increases when there is a decrease of 1 point in
structural social capital (odds=1.053 (1/0.950), p<0.001).
The results of this paper have signicant policy implications for the countries that comprise
both the EAC and SADC. From a policy perspective, it is imperative that policymakers consider
prioritising public preferences as intrinsic factors within the government’s policy priority-
setting processes. Incorporating citizens’ opinions into policy-making processes is fundamental
to adherence to the resulting policies, because as key stakeholders on the ground, public views
represent those of society as a whole.
COVID-19, Healthcare-Investment, EAC, SADC, Social Capital
Jacob Novignon and , Kwame Nkrumah University of Science and
Technology, Kumasi, Ghana
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The COVID-19 pandemic has exposed health system funding challenges across many
developing countries. The needed infrastructure to effectively respond to the pandemic was
absent in many developing countries. The inadequate resources meant that capacity to test,
contact-trace and treat was limited and lock down strategies were ineffective. This resulted in
policy makers resorting to various strategies to mobilize sufcient resources in response to the
pandemic. This paper reviewed Ghana’s efforts to mobilize domestic and external resources for
the health sector in response to the pandemic. The paper also evaluated lessons from these
strategies and highlights how these lessons could be leveraged to sustain nancing for the
health sector. To achieve this objective, we relied on information from three main sources; (i)
the 2020 mid-year national budget produced by the Ministry of Finance, (ii) ofcial documents
from the website of the private sector fund for COVID-19 and (iii) the Ministry of Health. We
conducted a desk review of these documents and extracted the necessary evidence. The
results support the existence of scal space through external sources, partnership with non-
state actors and effective public nancial management (budget space). While external sources
of nancing were critical in the pandemic response, we did not nd it to be sustainable,
especially for debt distressed countries. We also show that the COVID-19 pandemic presents
an important momentum to drive investment in health infrastructure across developing
countries. The lack of a clear pandemic response strategy was also identied to be a major
contributor to funding challenges. Steps to develop pandemic response strategies is, therefore,
highly recommended. Also keeping the momentum created by the pandemic will be
important to improve investment in the health sector.
1, Fatoumata Namaren Keita1, Alexandre Delamou1, Jean-Paul Dossou2, Jean-
Pierre Olivier de Sardan3, Wim Van Damme4 and Irene Akua Agyepong5, (1)University of
Conakry, African Centre of Excellence in the Prevention and Control of Communicable
Diseases, Conakry, Guinea, Conakry, Guinea, (2)Centre de Recherche en Reproduction
Humaine et en Démographie (CERRHUD), Cotonou, Benin, (3)LASDEL, Niamey, Niger, (4)
Public Health Department, Institute of Tropical Medicine of Antwerp, Belgium, Antwerp,
Belgium, (5)University of Ghana, School of Public Health, Accra, Ghana
The rst case of the COVID-19 pandemic was notied on 12 March 2020. This study aims to
assess the response process to the COVID-19 pandemic in Guinea, from the onset of the
pandemic in Guinea to September 2021.
We conducted a scoping review using policy documents and research papers on the COVID-19
pandemic in Guinea. For policy documents, we search through national COVID-19 electronic
platforms and websites of the government and key national health institutions. We conducted
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
a thematic analysis, using a deductive approach, to assess the studies.
Between January 2020 and September 2021, the response to the COVID-19 pandemic is divided
into ve phases: anticipation of the response; response to the rst wave with the sudden
boost of political actions alongside the implementation of strict restrictive measures; lifting of
restrictive measures; concomitant response to the second wave of the COVID-19 and several
epidemics-prone diseases; response to the third wave of COVID-19 including the strengthening
of vaccination activities. At the advent of the pandemic, ego and inuence struggles were
observed among key national health system actors, and this had likely affected the response
to COVID-19, and to recurrent epidemics in Guinea. In addition, certain restrictive measures
adopted during the response have had human and economic impacts on the population.
Health system actors anticipated the response to COVID-19 pandemic, and (re-) adapted
response strategies to the health and socio-economic context of the country as the pandemic
evolved. There is need to work towards setting-up a governing framework for epidemic-prone
diseases response with the full participation of national health system actors and institutions.
Policy decisions, Coronavirus, preparedness, response, Guinea.
1, Chioma Amarachi Onyedinma1, Benjamin Chudi Uzochukwu2 and
Obinna Onwujekwe3, (1)HPRG, Enugu, Nigeria, (2)University of Nigeria Enugu Campus, Enugu,
Nigeria, (3)University of Nigeria, Nsukka, Enugu Campus, Enugu, Nigeria
The COVID-19 pandemic has challenged the health systems of almost all the countries in the
world. A strong health system is characterized by its ability to respond to emergencies while
remaining resilient in delivering high-quality routine essential services promptly. This is not the
case in most low- and middle-income countries, of which Nigeria is one of them, making them
very vulnerable to COVID-19 pandemic. Prior to the pandemic, health systems had not received
adequate attention. However, with this pandemic, the country’s leadership has made efforts to
respond to reduce its spread. These efforts are worth documenting, as they will inform policy
makers and other stakeholders in Nigeria to reect on the ways to adopt and scale up the
positive measures identied.
A scoping review of published and grey literature including journals, news/ media documents
and ofcial documents that were published from 1st December 2019 to 31st December
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
2020 was conducted. The reviewers read and extracted relevant data using FACTIVA in a
uniform data extraction template. The template was structured in themes using the health
system building blocks and service delivery subtheme that captured technical support and
interventions targeted at health workers was used for the manual content analysis.
The identied interventions and strategies that have affected health service delivery were
mostly technical support and interventions targeted at health workers. These included
training of about 17,000 health workers, supervising and engaging more workers, upgrading
laboratories and building new ones to improve screening and diagnosis, motivation of health
workforce with incentives (nancial and non-nancial). There was an inux of philanthropic
gestures and improved data and information systems, supply of medicines, medical products
and non-pharmaceutical preventive materials through local production. Overall, the presence
of political will and the government’s efforts in health systems response to COVID-19 facilitated
these interventions.
s
The interventions of state and non-state actors have to some extent, strengthened the health
systems for improved service delivery. However, more needs to be done towards sustaining
these gains and towards making the health system strong and resilient to absorb the
unprecedented shocks.
COVID-19, Health systems response, strengthening health systems, Service delivery,
Nigeria.
, Department of Banking and Finance, University of Professional
Studies, Accra, Ghana
The importance of resilience of health systems to contain endemics and pandemics has
become an important international issue. For outbreaks increase mortality, reduce productivity,
and cause negative externality. Coronavirus disease 2019 (COVID-19) was one such outbreak.
Health expenditure reects investment in health. Public health expenditure has been found
to increase access to health services and improve health outcomes. There is, however, scarce
evidence on the relationship between public health expenditure and the resilience of health
systems to contain outbreaks.
This study explored the contribution of public health spending to the resilience of health
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
systems to contain the COVID-19 outbreak.
The study applied the probit regression model to cross-sectional data on 154 countries. The
data were sourced from the World Bank’s 2021 World Development Indicators and World
Health Organisation’s 2020 Coronavirus datasets.
A higher probability of containing the COVID-19 was associated with increases in public
health spending across time than in a year preceding the outbreak. Also, the results showed a
positive effect of population density and a negative effect of physician ratio and tertiary school
enrolment on the probability of a country reaching a COVID-19 endemic status.
Increases in public health spending over time increase the resilience of health systems to
contain outbreaks. Public health spending allocated to both public and private health facilities,
not only public health facilities, would increase the pace towards containing endemics.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Ileana Vilcu2, Anne Musuva3, Felix Murira3, Felix Murira3, and Nirmala
Ravinshankar4, (1)ThinkWell, Nairobi, Kenya, (2)ThinkWell, Geneva, Switzerland, (3)ThinkWell,
Kenya, (4)ThinkWell, WA
Kenya’s 2010 Constitution and 2012 Public Finance Management (PFM) Act mandate counties
to deposit all revenues to the County Revenue Fund. Counties run public health facilities and
are allowed, to develop their legislation to simplify fund ows to public facilities and grant
them autonomy to retain own-source revenues. The Ministry of Health (MOH) gave advisories
to allow public facilities’ managerial and nancial autonomy. However, there is variation in the
way counties interpret the PFM Act and advisories affecting service delivery at public facilities,
particularly during the COVID-19 pandemic.
This study examined the impact of PFM laws on public facilities’ in responding to the
population’s health needs during the COVID-19 pandemic. We purposively selected ve
counties (Isiolo, Kakamega, Kili, Makueni, and Nakuru) to capture variations in PFM
arrangements.
We conducted interviews with county health managers and focus group discussions with
public facilities managers to understand their experience with PFM arrangements, and how
these affected their COVID-19 response. We reviewed legislation that counties developed as
mandated by the PFM Act to assess how these affected PFM arrangements.
Key
While one county is developing legislation to respond to MOH advisories, the other four already
have such legislations. Two are reviewing their legislation to comply with the PFM Act and
simplify funds ow to facilities. Currently, the funds ow in these counties is complex resulting
in stock-outs of key supplies and unreliable transfers negatively affecting service delivery of
essential and COVID-19 response. The other two have compliant legislations that simplify funds
ow and grant autonomy to public facilities. Facility revenues representing 3% and 18% of
health allocations in these counties are used to cover a portion of facilities’ operation expenses.
This was benecial during COVID-19 in these two counties, allowing facilities to purchase
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
personal protective equipment and supplies as they waited for additional funding from
counties.
As purchasers of primary healthcare services, counties can build resilient health systems by
ensuring that public facilities have funds that they can exibly use. This proved to be critical for
facilities during the COVID-19 but also to improve quality service delivery in the public sector.
Correct application of PFM laws allows simplied funds ow empowering facilities to better
respond to population health needs.
, Ministry of Health, Lilongwe, Malawi, Atamandike Chingwanda, Health Policy
Plus Project-Palladium Group, Lilongwe, Malawi, Mark Malema, Options Consultancy Services
Ltd, Lilongwe, Malawi and Martina Mchenga, World Health Organization, Lilongwe, Malawi
Tracking Covid-19 health expenditures is a key policy tool for informing the efciency and
equity of the Covid-19 response. Expenditure tracking in emergencies also serves as an
important source of transparency and accountability in the context of large ows of funds and
limited duciary risk assessments. In Malawi, Covid-19 health expenditure tracking was even
more important given the fact that the health system is ordinarily characterized by leakages,
donor fragmentation and inefcient allocation of resources.
To inform the efciency and equity of future investments in response to the Covid-19 pandemic
and build a more resilient health system.
An Excel data collection tool was designed in line with the System of Health Accounts
framework. The tool was used to capture Covid-19 health expenditure data for 2020 across
healthcare nancing agents, implementing agents, and level of implementation. Data were
collected from government institutions, donors, and non-state implementers of donor-funded
programs through workshops and via emails. The National Health Accounts Production Tool
was used to analyze the expenditure data.
Our ndings show that the total Covid-19 health expenditure, TCHE in 2020 was US$93, 869,153,
which translates to US$5.34 per capita. Donors contributed 80.6% of TCHE, the government
contributed 10.2%, and the private sector contributed 9.2%. Government Covid-19 health
expenditure as a share of TCHE is signicantly small relative to Burkina Faso (78.7%) which has
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
a similar per capita health expenditure (US$40). 84% of the TCHE were new additional funds
to the healthcare system. There was limited exibility in spending with 84% of TCHE strictly
earmarked for activities.
62% of TCHE was pooled under non-prot institutions serving households (NPISHs), 27.8%
under non-resident donors and 10.2% under government. Curative spending at 15.8% of TCHE
was relatively low despite the healthcare system requiring massive infrastructure, medical
equipment and health worker investments in response to the pandemic. Sub-national
spending was also not related to actual or anticipated disease burden as Lilongwe (24% of total
cases) and Blantyre (34% of total cases) had 1.8% and 1.5% of sub-national level expenditures,
respectively.
The Government of Malawi should increase health budgets towards the Covid-19 pandemic
response. Efciency and equity can be improved through more exibility in the allocation
of funds amongst Covid-19 activities and through focusing more on potential hotspots. The
major limitation of the study is that it does not include household-level data due to time and
nancial constraints.
1, Oluwafeyikemi Agbola1, Simbiat Lawal2, Hope Uweja3 and Stanley Chibuzor
Ezenwa3, (1)Results for Development (R4D), Abuja, Nigeria, (2)Results for Development, Abuja,
Nigeria, (3)Results for Developments (R4D), Abuja, Nigeria
As low- and middle-income countries (LMICs) pursue universal health coverage (UHC), the
strategic use of public nancing is critical for making progress towards more equitable
coverage. Governments’ challenges stem from being able to connect nancing with
achieving UHC. Most public-sector healthcare funds in many LMICs are often deployed
through traditional input-based, line-item budgets and channelled via routine PFM systems.
An assessment of the PFM cycle of the FMOH highlighted the disconnect between budget
and UHC priorities and informed the technical support provided by Results for Development
(R4D) for the reform of FMOH’s budget process through funding by the Bill and Melinda Gates
Foundation (BMGF).
This paper highlights how R4D supported FMOH to make its budgets more targeted, aligned
to priorities, with stronger monitoring mechanisms for tracking output performance across
different domains. The expected outcome of R4D’s support is for the FMOH to make health
care expenditure more strategic and results-oriented.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
This support adopted a Human Centered Design (HCD) and three propositions based on R4D’s
work in-country to reform PFM systems to become more strategic:
1. Employing a “whole-of-government” perspective for budget formulation and execution
2. Targeted/results-based, routine monitoring and evidence generation to track output
performance
3. Formation of an explicitly designated, well-designed collaborative unit; a planning and
budget committee (P&B Committee) within the health ministry
Key
This support has revealed that:
• To track the budget seamlessly, it is important for the priority activities in the annual
operational plans (AOP) to align with those in the budget.
• To address communication breakdown, a common language that appeals to the
ministry’s departments, agencies and programmes (DAPs) is required to form a unied
approach to the budget cycle concerning health objectives.
• Frequent changes in the membership of the committee and leadership ux at the
FMOH were key variables that inuenced the outcomes.
• Finally, the bureaucratic bottlenecks of the system and inadequate government funding
impacted timelines of planned activities and expected results.
This support has conrmed the importance of tracking budget performance in building a
better health system. It has also provided evidence-based information to advocate for more
resources from the government to fund these processes adequately. Finally, funding, technical,
and civil society partners can prioritize this budget process-focused agenda as a salient
component of broader PFM and strategic purchasing reforms in Nigeria.
1, Augustine Aghogho Omodieke2, Olasunmbo Makinde3, Chinwe Weli3,
Julie Wieland3 and Zeluwa Maikori3, (1)Health Strategy and Delivery Foundation, Lagos,
Nigeria, (2)Health Strategy and Delivery Foundation, Abuja, Nigeria, (3)Health Strategy and
Delivery Foundation
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
A major challenge that has plagued healthcare organizations in low- and middle-income
countries (LMICs) is poorly managed nancial systems. In healthcare, an efcient scal system
ensures that scarce resources and risks are optimized to help achieve sustainable nancial
goals and aid the delivery of quality healthcare services to patients. Establishing effective
nancial governance and control systems, transparent and detailed nancial reporting,
adequate cash ow and cash handling management amongst others are requisite for
organizing an effective nancial management system. This paper highlights the impacts of a
weak nancial management system on service delivery in a West African tertiary facility.
Our assessment approach was both qualitative and quantitative. First, we developed
a comprehensive nancial management assessment tool (FMAT) with a focus on key
domains including nancial governance, budget and planning, internal control, information
systems relevant to nancial reporting, insurance/payor administration, cash, and revenue
management. In addition, a patient satisfaction survey tool was developed. Second, we
assessed the facility’s scal system using the assessment tool via a mix of process observation,
key informant interviews and review of relevant documents. Third, we analyzed assessment
data using a thematic and narrative analytic approach. We held a co-creation session with the
facility’s management team to develop and prioritize high-impact and low-cost interventions
to address identied weaknesses.
Results from the assessment revealed signicant weaknesses in the hospital’s overall nancial
management system. The nancial management system had an average quantitative score
of 36% which indicates a low performance and medium risk rating. Weak internal control/
audit systems, inefcient nancial information systems, poor cash and revenue management
practices predisposed the facility to nancial losses and fraud. Several interventions were
co-developed with the stakeholders, including expert coaching on nancial reporting and
controls to the scal team, and the development and use of requisite nancial policies and
guidelines. These interventions have led to streamlining of the cash collection process through
outsourcing, with the construction of central cash points ongoing. Institutionalization of
periodic audits and monthly nancial performance reviews have also been implemented to
strengthen the facility’s scal system to improve the efciency of revenue generation and
expenditure.
1, Kimberly Idoko1, Paul Ongboche1, Habibah Umar2, Hauwa Aliyu3, Musa Musa4 and
Yewande Ogundeji5, (1)Health Strategy and Delivery Foundation, (2)Niger State Contributory
Health Insurance Agency, (3)Niger State Planning Commission, (4)Niger State Contributory
health insurance agency, (5)Health Strategy and Delivery Foundation, FCT, Canada
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Public nancial management (PFM) in health systems offers an opportunity to improve the
efciency of public spending through proper accountability and transparency, planning, and
control of nancial activities. In addition, health nancing reforms in many countries include
the implementation of health insurance schemes and decentralized facility nancing, which
both have a critical PFM component. However, historically, there has been less emphasis on
the role of PFM in health nancing and health systems reform. Our paper describes the design
and effects of a PFM intervention for primary healthcare at the sub-national level in Nigeria.
The PFM interventions were designed to address specic challenges identied by a previous
diagnostic of the health system, which highlighted weak technical capacity, and oversight
needed for effective PFM for primary health care (PHC). These PFM interventions included:
•
targeted capacity building of 25 LGA PHC accountants to improve both computer
literacy and PFM skills required to prepare, review, and utilize nancial reports.
Accountants acquired capacity and began submitting monthly reports timely.
•
A mobile platform was created through the WhatsApp mobile application between April
to September 2020 to enable reporting summaries of nancial transactions and virtual
technical support and mentorship.
•
To encourage institutionalization and ownership, mentors from within the state PFM
technical working group were trained to provide virtual technical assistance on the
mobile platform. However, low demand for and use of nancial reports by oversight
Agencies potentially affects sustainability.
Over 80% of Facility Managers trained showed signicant improvement in PFM knowledge
and processed based on pre and post-test scores. In addition, the timely submission rate of
nancial reports increased from 0% in March 2020 to 86.7% by September 2020 across all
pilot facilities. Data from the nancial reports aided the PHC system fund transparency and
accountability at the service delivery level. However, towards the end of the pilot, motivation
from the state mentors on the virtual app had signicantly reduced and there was limited
demand for nancial data from oversight agencies for PHC
Targeted interventions on PFM yield considerable results in improving the capacity of key
actors and establishing best practices and procedures for nancial reporting. However,
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
oversight agencies at the subnational levels must increase the effectiveness of their
coordination role through regular demand for nancial reports and the status of nancial
management at the PHC facilities to ensure that the gains are sustained after the project.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Fan Yang1, 2, Bram Roudijk3, Zhihao Yang4, Paul Revill5, Susan Grifn1,
Perez Nicholas Ochanda6, Mohammed Lamorde6, Giulia Greco7, Janet Seeley8, Janet Seeley8
and Mark Sculpher1, (1)Centre for Health Economics, University of York, United Kingdom,
(2)MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda, (3)EuroQol Research
Foundation, Netherlands, (4)Health Services Management Department, Guizhou Medical
University, China, (5)Centre for Health Economics, University of York, York, United Kingdom, (6)
Infectious Diseases Institute, Makerere University, Uganda, (7)MRC/UVRI & LSHTM Uganda
Research Unit, Uganda, (8)London School of Hygiene and Tropical Medicine, United Kingdom
In African countries, methods of health technology assessment including economic evaluation
have been increasingly used to inform healthcare resources allocation decisions. However,
until September 2021, only one EQ-5D-5L value set for Ethiopia was available. As the EQ-5D
value set reects the social preferences of a population, a country-specic EQ-5D-5L value set
is preferred and would provide valuable information to inform future economic evaluations in a
context where better decisions regarding resource allocation are essential.
The standardised EQ-5D valuation protocol requires a representative sample of 1,000
participants from the general population with each completing 10 composite time trade-offs
(cTTO) and 7 discrete choice experiment (DCE) tasks, which could be resource-intensive and
cognitively burdensome.
Therefore, in this study, we proposed a ‘lite’ version of the EQ-5D-5L valuation protocol,
requiring a smaller sample by collecting more cTTO data from each participant and applying it
to develop an EQ-5D-5L value set for Uganda.
Adult respondents from the general Ugandan population were quota-sampled based on
age and sex. Eligible participants were asked to complete 20 composite time trade-off (cTTO)
tasks in the tablet-assisted personal interviews using the ofine EuroQol Portable Valuation
Technology software under routine quality control. No discrete choice experiment task was
administered.
The cTTO data were modelled using four additive and two multiplicative regression models.
Model performance was evaluated based on face validity (larger decrements for more severe
problems), prediction accuracy in cross-validation and in predicting mild health states. The
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
nal value set was generated using the best-performing model.
A representative sample (N=545) participated in this study. Responses to cTTO tasks from
492 participants were included in the primary analysis. All models showed face validity and
generated comparable prediction accuracy. The Tobit model with constrained intercepts and
corrected for heteroscedasticity was considered the preferred model for the value set based on
better performance.
In the nal value set, the relative importance of dimensions is pain/discomfort (most
important), mobility, self-care, usual activity and anxiety/depression (least important). The value
set ranges from -1.116 (state 55555) to 0.943 (state 11112, 2nd best) and 1 (state 11111, full health).
This is the rst EQ-5D-5L valuation study using a ‘lite’ protocol involving cTTO data only. Our
results suggest its feasibility in resource-constrained settings. The established EQ-5D-5L
value set for Uganda is expected to be used for economic evaluations and decision making in
Uganda and the East Africa region.
, Institut de Recherche en Science de la Santé, Ouagadougou,
Burkina Faso, Corneille Traore, CNRFP, Ouagadougou, Burkina Faso and Eve Worall, LSTMED,
Liverpool, United Kingdom
Vector-borne diseases (VBD) are responsible for over 17% of all the infectious diseases globally
causing more than 700,000 deaths annually. Despite the availability of effective interventions
for many Vector-borne diseases, a lack of resources prevents their effective control. More
nancial resources are required for VBD control. But there is little published information about
the domestic and international nancial resources allocated to VBD. More specically we do
not know much about levels, trends and allocation of domestic and donor nancing of VBD
related activities. Thus, there is a need for empirical assessments to determine current resource
allocations. The specic objectives of this study were to map the main funders of VBD in
Burkina Faso and to explore how investment decisions on VBD by the funders who reported
data from 2015-2018 have been allocated among diseases and particular activities.
Our research framework was grounded in political economy analysis and different frameworks
in public policy analysis. The study was a case study design focused on Burkina Faso and
primarily based on secondary data in addition to some qualitative analysis. Budget allocation
and expenditures data from 2015 to 2018 were collected from the NTD program and a fund
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
management institution of the Ministry of Health. Annual reports and nancial reports
were used for data extraction. Data were extracted from these datasets and pooled in a
unique database. The database included variables such as Budget mobilized and allocated,
expenditures, source of funding and type of activity. The descriptive analysis explored levels,
trends and allocation of domestic and donor funds for VBD.
Most of the sources were from external donors (7/8). The government has funded only 4%
of activities. The trend of sources of nancing was discontinued. Over time some sources
disappeared and some appeared. Sources were 5 in 2015 and 2016, 4 in 2017 and 6 in 2018.
In terms of activities, 28% of activities were related to prevention followed by surveillance
and monitoring and evaluation from 2015 to 2018. There were few variations between
mobilized, allocated and expenditures over time. In terms of expenditures, more than 85% of
allocated resources were spent. Activities were mainly concentrated in Lymphatic lariasis,
onchocerciasis and schistosomiasis.
The ndings highlighted the persistent dependence of health nancing on donors’ funds. This
situation questions the sustainability of activities for vector-borne diseases control and the
achievement of elimination of vector-borne diseases in low incomes countries.
1, Justice Nonvignon2, Robert van Der Meer1 and Itamar Megiddo1, (1)
University of Strathclyde, Glasgow, United Kingdom, (2)Department of Health Policy, Planning
and Management, School of Public Health, University of Ghana, Legon, Ghana
Decision analytical models (DAMs) are used to develop an evidence base that is used in
impact and health economic evaluations, including to evaluate interventions to improve
diabetes care and health service—an increasingly important area in low- and middle-income
countries (LMICs), where the disease burden is high, health systems are weak, and resources
are constrained. Compared with large-scale real-life randomised control trials and cohort
studies, DAMs can produce evidence of the health and economic benets of interventions in
an affordable and timely manner, while overcoming ethical issues, by using mathematical and
logical relationships to abstract vital aspects of reality/systems for analysis.
This study examines how DAMs, Markov, system dynamic, agent-based, discrete event
simulation models, and hybrid of these models have been applied to investigate non-
pharmacological (NP) policy interventions, what gaps exist in their use, and how to advance
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
their adoption to diabetes research in LMICs.
We conducted a systematic search of peer-reviewed articles published in English between
2000 and 2020 in PubMed, Cochrane, and the reference list of reviewed articles. Articles were
appraised based on publication details, model design and processes, modelled interventions,
and model limitations.
Key
Thirteen studies were included (six Markov, six microsimulation and one agent-based model),
most of which modelled interventions in the Chinese subpopulation. All studies, except one,
assessed health-targeted interventions. Almost half did not report on the type of model
validation conducted Among the six studies reporting model validation, four conducted
external validity and two combined four validation types: face-validity, internal, external, and
cross validity. Twelve out of the thirteen reviewed studies reported uncertainty analysis. Most
studies do not report on model validation or economic evaluation of interventions. Only
four studies modelled policy interventions among diabetes patients; most studies were on
sub-populations at risk and only one scal policy (tax increment) was evaluated. All studies
reported limitations with obtaining sufcient data for modelling.
: This review provides a summary of DAMs used in studying NP diabetes interventions in LMICs
to identify existing gaps in their adoption and how to advance the development of appropriate
DAMs for studying NP policies intervention for controlling diabetes. The study recommends
that LMICs should leverage the usefulness of DAMs for developing evidence to support
economic evaluation of population-wide NP policy interventions, particularly scal policies, for
controlling their escalating diabetes burden.
1, Sarah Martin1, Onajite Otokpen2, Hyeladzira Garnvwa1 and Muhammad
Awwal Abdullahi3, (1)National Primary Health Care Development Agency (NPHCDA), Abuja,
Nigeria, (2)Solina Group, Nigeria, (3)Sydani, Abuja, Nigeria
Policy makers must make choices about the allocation of scarce resources given budget
constraints. Decisions have become increasingly pressing since the COVID-19 pandemic with
weak efforts at ring-fencing. To inuence budgetary decisions, policy must be evidence-based.
Health Benets Packages (HBP) are a tool frequently used in low-resource settings for priority
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
setting to ensure more can be delivered given resource constraints.
Using a framework for HBP design to assess the cost-effectiveness of interventions currently
included in Nigeria’s Ward Health Service (WHS) package. Modelling the optimal benets
package for Nigeria based on the current budget and using a feasibility study to assess the
net health losses that could be resolved through systems strengthening and additional PHC
investments.
A model was created in Microsoft Excel. Incremental Cost-Effectiveness Ratios (ICERs) were
applied to interventions based on the current WHS package, using the Tufts Global Cost-
effectiveness Analysis Database. Interventions were then compared to a Cost-effectiveness
Threshold (CET),[1] and those with an ICER below the CET were deemed cost effective. Per
patient costs and DALYs averted for each intervention were estimated with inputs from the
One Health Tool, and then scaled up to population estimates. The Net Health Benet (NHB) of
the total service package was estimated to understand the health gain which can be achieved
by providing services at capacity utilisation (100%) with the implicit budgetary requirement.
Varying feasibility constraints were applied to reect different levels of health system utilisation.
This was used to estimate the consequences of Nigeria’s current health systems constraints,
primarily from under-investment, i.e., how much NHB is being lost from not having a fully
functioning health system.
The model estimates the optimal HBP for Nigeria given the current health budget and
expected impact of population health; whilst also indicating the cost to the health system
of current constraints (both supply and demand side) as demonstrated by the loss of net
economic benet. The model also highlights where investments in scaling-up interventions
could be made versus investment in system strengthening to enable increased coverage. This
can inform effective resource allocation decisions based on current HBP expenditure; and
inuence new investments in system strengthening.
can be used to prompt further discussion between government, donors and
stakeholders around the trade-offs involved in the provision of health services, increased health
investment, and resource allocation.
[1] Estimated CET for Nigeria is based on Ochalek et al. (2018) range of $214-$291
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Noemi Kreif2, Peter C. Smith2, Nicholas Stacey3, Ijeoma Edoka4 and Rita Santos2,
(1)University of York, Addis Ababa, Ethiopia, (2)University of York, York, United Kingdom, (3)LSE
Wits University, Johannesburg, South Africa, (4)University of Witwatersrand, Johannesburg,
South Africa
An increasing number of LMIC health systems are developing, standardising and routinely
measuring quality indicators in order to evaluate quality standards and indicate areas –
both geographic and thematic – of poor performance. While measuring quality can reveal
shortcomings, it is debatable whether, without accompanying material incentives, this is
sufcient to improve quality in circumstances it is revealed to be sub-par. Recent evidence
has suggested that performance measurement may be able to induce health care quality
improvements through intrinsic motivation and reputational concerns
We investigate whether health facilities in South Africa adapt their quality in response to
changes in quality measures of their ‘peer’ health facilities, even in the absence of material
incentives for doing so. Specically, we examine whether public reporting of a standardised
measure of facility quality can induce a form of yardstick competition based on comparative
performance information.
Using a census of public primary health facilities in the country, we exploit data on ten
structural and process components of quality, examining how these measures change from
2014/15-2016/17. We examine facilities strategic interactions using both a spatial econometrics
approach and a more traditional approach exploiting a quality improvement programme as a
source of exogeneous variation to estimate the response of facilities to changes in the quality
of their peers.
Key
Our results suggest that even without accompanying nancial reforms, linking facilities
reimbursement with quality indicators, measurement and reporting may be sufcient to
stimulate quality improvements.
s
These ndings strengthen the case for improving data collection systems and suggests
there may be alternatives to health nancing reforms for improving the quality of health care
delivered. An increasing number of health care systems in low- and middle-income countries
are introducing and routinely measuring quality indicators at health facility-level, however,
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
much focus for improving the quality of health care supplied has been on nancial reforms.
This suggests that peer-to-peer quality reporting may have similar quality improvement
potential. Further research is required into the precise mechanisms such quality reporting acts
upon to understand if public reporting is a potential substitute or complement to nancially
induced quality improvements.
, Africa Centres for Disease Control and Prevention (Africa CDC), Health
Economics Unit, Addis Ababa, Ethiopia, Mahlet Kie Habtemariam, 2. Africa Centres for
Disease Control and Prevention, East African Region Collaborating Center (RCCs), Nairobi,
Kenya and Nonvingon Justice, 1. Africa Centres for Disease Control and Prevention, Health
Economics Unit, Addis Ababa, Ethiopia
The COVID-pandemic signicantly affects the global economy and in particular the African
continent. As part of the response to this pandemic, a continental based organization,
Africa CDC, has developed a wide range of response and mitigation strategies. To curve the
pandemic, there exist theoretical understandings that economic evaluation (EE) can play an
important role in priority setting at the different levels. There exists limited EE applicability
within the contexts of public health emergency management (PHEM) which are characterized
by recurrent and unexpected disease outbreaks as well as its impact on resources for
managing health consequences of natural and human-made disasters, emergencies, crises,
and conicts.
This qualitative analysis aims to highlight the role of EE within the context of public health
emergency management (disease outbreak warning and response) setting and assess the
possible impact in the public health emergency management of disease outbreaks and
response in Africa.
A purposive sample of twelve key informants within Africa CDC was selected, and the
participants have acquired an extensive work experience within Africa CDC and were
nominated in line with the study purpose. A qualitative analysis technique, employing a key
informant guide, was used for the interview sessions and a series of consultations made to
shape the themes. Supplementary document reviews such as strategic documents, policy
guidelines and statements were conducted. Four themes from the qualitative analysis were
identied and employed the logic model to illustrate further the casual link and possible
impact chain of EE within the PHEM settings.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
With a continuing COVID-19 global pandemic and future possible global health security
concerns, EE could play a wide range of roles highlighted across the public health emergency
management cycle (PHE preparedness, early warning, response and recovery) for the
continental decision-making as well as to strengthen country’s public health emerging
outbreaks response decisions. The role of EE was dened for generating evidence related
to the value-for-money, for investing in the emergency management of the disease in the
continent, relevance to consider resource/economic cases in outbreak preparedness and
response and synthesizing evidence to inform policy decision-making.
A huge potential role of EE can be maximized in the public health emergency management
sitting to effectively and efciently use the limited resource in the continent, and there is a
need to widen the applicability of EE tools and methods across the emerging disease outbreak
management at different levels.
Page 39
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Faculty of Medicine, University of Mahajanga, Madagascar,
Antananarivo, Madagascar, Franck Maherinirina Rakotomalala, Faculty of Medicine,
University of Antananrivo, Madagascar, Antananarivo, Madagascar and Jack Chola Bwalay,
School of Social Policy, Social Work & Social Justice, University College, Dublin, Ireland
Having caused unprecedented damage to the healthcare service delivery systems in
Madagascar, the Coronavirus (Covid-19 pandemic), remains a major public health threat.
The rst case of Covid-19 in Madagascar was declared on March 19, 2020, and by the end of
September 2021, the country had over 42,392 conrmed cases and 928 recorded deaths.
This study describes the impact of the Covid-19 pandemic on the users of community public
healthcare facilities during the period 2019 – 2020 in Madagascar.
We used data from the Information System of the Ministry of Public Health, DHIS2 covering
the period from January 1, 2019, to December 31, 2020. We analyzed the indicators of the
use of community healthcare facilities including the rates of use of family planning services,
vaccination coverage (DTP3), antenatal-care services, delivery at the health center, and
outpatient consultation services
A decrease of 3.2% points in the contraceptive prevalence rate was observed, falling from 27.6%
in 2019 to 24.4% in 2020. The coverage rate of DTP3 dropped from 92.2% in 2019 to 86.4% in
2020. Prenatal care declined from 35.1% to 29.2%. Outpatient visits (47.3% in 2019 to 46.3% in
2020) and childbirth at health centers dropped from 33.7% in 2019 to 28.9% in 2020.
This study demonstrated that access to healthcare facilities during the early stages of the
COVID-19 pandemic impacted community healthcare service users particularly for child and
maternal healthcare. Devising effective strategies for maintaining access to healthcare services
as Covid – 19 continue to play out during this epidemic are recommended.
, University of malawi, Zomba, Malawi
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The COVID-19 disease has been very disruptive to all health systems across the globe. Malawi
reported her rst three COVID-19 cases in April 2020 in Lilongwe soon after Government
declaring a State of national disaster to manage the COVID-19 pandemic. Being a novel
disease, its impact on service use is not clear but it is possible a rational being would shy
away from using healthcare services either in anticipation that healthcare providers are
overwhelmed with taking care of COVID-19 patients or be afraid of contracting the disease as
healthcare facilities are congested with COVID-19 patients.
This study assessed the impact of the COVID-19 pandemic on use of maternal care services in
Malawi.
Using interrupted-time-series analysis of monthly administrative data between January
2017 and March 2021, the study assessed whether the level and trend of number of pregnant
women with at least four ANC visits, number of pregnant women with their rst ANC visit in
the rst trimester, and facility delivery changed.
At the national level, while the level remained unchanged, the trend of ANC visits per pregnant
woman decreased by 100 women every month (p=0.045). There was no observed impact on
number of pregnant women with their rst ANC visit in the rst trimester, and facility delivery.
In the Northern Zone, the level and trend of number of women with at least four ANC visits
decreased by 223 (p=0.009) and 13 (p=0.034), respectively. The level of facility delivery decreased
by 347 (p=0.009). For the Central Eastern Zone, the level of the number of women with at least
four ANC visits decreased by 265 (p=0.018) while the trend in women who delivered at a health
facility decreased by 83 women per month (p=0.003). In the Central Western Zone, the number
of women who had at least four ANC visits decreased by 34 women per month (p=0.008).
Lastly, in the Southern Eastern Zone, the number of women who had at least four ANC visits
decreased by 348 women per month (p=0.038).
The ndings suggest the pandemic suppressed service use implying that while it is very
important to attend the needs coming with the pandemic, efforts should be made to ensure
those in need of other healthcare services are attended to otherwise the potential negative
effects could be devastating, especially in contexts like Malawi where maternal healthcare
outcomes are sub-optimal.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Paul Olaiya Abiodun2, Ali Johnson Onoja3, Freddy Rukema Kaniki4
and Elizabeth Abike Sanni1, (1)Fescosof Data solutions, Ota, Nigeria, (2)Laboratory Services,
Management Sciences for Health, Compliance and Quality control Department, Akesis, Anuja,
Nigeria, (3)African Health Project, Abuja, Nigeria, (4)Department of Health Sciences, Eben-zer
University, Minembwe, Congo (The Democratic Republic of the)
The lockdown policy imposed in response to the COVID-19 pandemic has restricted various
businesses, including trading, interstate travel for purchasing/selling and supplying goods and
services, hospitality industries, and state revenue generation. This study assessed the impacts
of COVID-19 lockdown on the economy of a Nigerian low-resource community.
This study was a descriptive cross-sectional survey conducted in Ado-Odo Ota local
government area (LGA) of Ogun State, Nigeria. A structured questionnaire was used to collect
data on the economic impacts of COVID-19 lockdown from 383 participants aged 20 to 60
years in January and February. Data analysis was done using IBM-SPSS version 25.
Only 29.2% were doing their main works during the lockdown, 26.1% lost their jobs, 34.5%
experienced salary cuts, only 6.5% got regular salaries, 6.0% worked from home and received
full payment. Concerning livelihood during COVID-19 lockdown, more than half (53.8%)
said they could not meet basic needs. All respondents (100.0%) said food prices and other
necessities were higher during the lockdown than before. The rate at which people lost their
jobs during the lockdown was 18.74 [95%CI-6.20 – 56.60; p<0.001] and 4.32 [95% CI-1.50 – 12.43;
p<0.001] higher among the staff of private organizations and those doing personal businesses
than among government workers. The rate of clients/customers loss was 15.21 [95% CI-7.59 –
30.51; p<0.001) and 7.07 [95% CI- 3.26 – 15.34; p<0.001] higher among self-employed and private
companies than government establishments.
Every worker should have job security to mitigate job and income loss during a crisis. The
government should also make loans and grants available for small businesses, particularly
during times like this. Government should provide food security by subsidizing goods and
providing palliatives to help meet the daily needs of hard-hit during crises, which would help
limit the emergence of criminal activities.
COVID-19, lockdown, economy, pandemic, coronavirus
Page 42
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Centre de connaissances en santé en RDC, Kinshasa, Congo (The
Democratic Republic of Congo)
Since the beginning of 2020, the COVID-19 epidemic has spread around the world. In all
affected countries, governments have taken strong measures to stop the spread of the
epidemic. In the DRC, where the rst case of Covid-19 was notied on 10 March 2020, the
President of the Republic declared a state of health emergency from 24 March to 21 July
2020, accompanied by measures to reduce interaction and population movements (closure
of borders, suspension of ights from high-risk countries, ban on gatherings of more than 20
people, ban on the opening of discotheques, bars, terraces, restaurants, etc.). The application of
these measures has had an impact on the lifestyle of the population, more than 80% of whom
live from economic activities in the informal sector.
This study was to determine the socio-economic impact of the measures taken against the
Covid-19 epidemic during the state of health emergency.
This is a case study based on a literature review, combining grey and scientic literature
complemented by in-depth interviews with health authorities and opinion leaders.
The DRC has suffered a serious shock from the Covid-19 pandemic: Less than 6% of companies
in three major cities of the DRC (Kinshasa, Goma, Lubumbashi) have put employees on
technical leave since April 2020. In Goma, 13% of economic units have given technical leave
to their employees, 59% of whom are women. The measures taken against the pandemic are
having a signicant impact on local import-dependent activities and on the informal sector.
Approximately 55% of households have seen their incomes fall. There has been an estimated
loss of revenue of $40 million for the airline company Congo Airways; $3.3 million for the
Congo National Railway Company; and $6.68 million due to the closure of bars, restaurants
and terraces. There was also an economic recession. A very sharp depreciation of the national
currency was noted, from 1,750 to 1,850 FC/USD.
In the DRC, the health emergency against covid-19 has jeopardised the informal sector on
which the majority of the population depends. As a result, they should be rethought in their
implementation to mitigate the deleterious effects on the population.
Covid-19, effects, informal economy, DRC
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University of Ghana School of Public Health, Accra, Ghana
Decline in healthcare utilization in low-and-middle-income countries (LMICs)
due to the Covid-19 pandemic could reverse decades of progress in improving health outcomes
and further put people at increased risk of avoidable illness and death. Understanding
healthcare utilization during pandemics is crucial to inform policy and to prepare health
systems for future pandemics. This study examined healthcare utilization among the general
public and associated factors during the rst wave of the Covid-19 pandemic in Ghana
A cross-sectional public survey using a structured self-reported questionnaire was conducted
between May 23 and July 11, 2020, during the rst wave of conrmed COVID-19 cases and after
the fth week of a partial lockdown in Ghana. A convenience sampling approach was used to
recruit the respondents virtually through advertising on social media platforms. A total of 643
respondents consented to the study by completing the survey. Data were analysed in Stata
version 15. Descriptive, bivariate and binary logistic regression analyses were carried out. A
value of P<.050 was considered to be statistically signicant.
The prevalence of healthcare utilization among the general public during the rst wave of the
COVID-19 pandemic was 27.4%. About 15.9% of the respondents reported unfair treatment at
the health facilities while 16.5% were not satised with the services provided. About 15.6% of
the respondents did not utilize healthcare for fear of getting the virus at the health facility. Fair
treatment by health providers (adjusted OR = 1.80; 95 % CI = [1.025, 3.165]; P < 0.05), drinking of
alcohol (adjusted OR = 1.80; 95 % CI = [1.025, 3.165]; P < 0.05) or taking of drugs (adjusted OR =
1.80; 95 % CI = [1.025, 3.165]; P < 0.05) to help get through the fear caused by the Covid-19, marital
status (P < 0.05) and possession of valid health insurance (adjusted OR = 1.80; 95 % CI = [1.025,
3.165]; P < 0.05) were statistically signicantly associated with health service utilization.
A resilient health system that ensures fairness in treatment of all is needed to improve
healthcare utilization among general public during pandemics especially in LMICs. Timely
public education to alleviate fear at the health facility level and promote early health seeking
treatment during pandemics are needed.
Page 44
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
: Nirmala Ravishankar, ThinkWell, Michael Chaitkin, MPH, ThinkWell, Kampala,
Uganda, Marie-Jeanne Offosse, ThinkWell, Ouagadougou, Burkina Faso, Salomão
Lourenço, ThinkWell, Mozambique, Gemini Mtei, Abt. Associates Inc., Public Sector Systems
Strengthening Plus (PS3+) Project, Dar es Salaam, Tanzania, United Republic of, John
Kinuthia, International Budget Partnership, Kenya, Dr. Hélène Barroy, PhD, WHO, Geneva,
Switzerland and Ileana Vilcu, ThinkWell, Geneva, Switzerland.
In recent decades, most countries around the world have embarked on decentralization
processes that affect health service delivery. Concurrently, public nancing has grown
faster than any other source of health expenditure, leading to increased attention to how
effectively, efciently, and equitably governments spend public money on health. As a result,
public nancial management (PFM) systems are increasingly recognized as key enablers
of effective health nancing reforms towards universal health coverage. In many settings,
health system performance depends on coherence among decentralization, PFM, and health
nancing reforms—where they are disconnected or poorly coordinated, service delivery can
suffer. Despite these important relationships, only recently have there been focused efforts
to systematically assess how decentralization affects PFM processes and, in turn, health
service provision. There remains a lack of understanding among many health stakeholders
about how PFM operates and how functional and nancial roles are distributed and fullled
in decentralized contexts. Consequently, to guide suitable policy responses, there is a need
to further unpack PFM processes and identify bottlenecks affecting health service delivery in
decentralized countries.
This session will explore how decentralization has shaped PFM processes in the health sector,
including budget development, approval, execution, and accountability. It will draw on a
learning initiative undertaken by ThinkWell and the World Health Organization to document
the decentralization and PFM dynamics shaping the health systems of eight counties:
Burkina Faso, Indonesia, Kenya, Mozambique, Nigeria, the Philippines, Tanzania, and Uganda.
The session will open with a cross-country analysis of key PFM bottlenecks resulting from
decentralization in the eight countries, highlighting the implications of misalignments
between PFM and decentralization reforms for health nancing and service delivery. Next,
case study authors from Burkina Faso, Mozambique and Tanzania will share insights from
their countries, elaborating on the implications of decentralization and PFM reforms for health
system performance. Two expert discussants will then reect on the policy implications of
the featured countries’ experiences. Finally, the chair will moderate a discussion among the
panelists and discussants, including questions and comments from the audience.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Michael Chaitkin, MPH, ThinkWell, Kampala, Uganda
Public nancial management (PFM) systems are increasingly recognized as key enablers
of effective health nancing. As countries strive toward universal health coverage, there is
growing attention to whether governments spend public funds effectively, efciently, and
equitably. Additionally, most countries have decentralized a range of public functions. How
decentralization affects service delivery depends on how well it coheres with health nancing
and PFM reforms.
This study describes how decentralization has shaped PFM processes in health, examines
bottlenecks and their effects on health service delivery, and offers policy lessons based on the
experiences of eight countries.
A synthesis analysis was conducted of case studies commissioned on the eight countries. Each
case study combined extensive document and data review with semi-structured interviews
and consultations with purposively selected experts and health system stakeholders. Country
ndings were collated by phase of the budget cycle and analyzed for common and divergent
practices, challenges, and policy solutions.
Key
Bottlenecks and remedies were categorized by budget stage.
• Decentralization complicates health budgeting. Disparate budget
structures and fragmented nancing hinder collaboration across levels, contributing to
disjointed sector plans and low budget prioritization for health. Countries can implement
more exible budget structures and better align them across levels.
• Budget approval practices often diverge from guidelines. Decentralized
countries can benet from further formalization and transparency of approval processes.
• Overestimated revenue forecasts undermine budget performance,
as do convoluted procedures for moving money throughout the system. Countries
can develop more realistic budgets and streamline funds release. Additionally,
decentralization does not guarantee autonomy at the provider level; in fact, facilities often
lose independence in the early stages of decentralization reforms. Over time, countries
recognized these harms and started putting more money under facilities’ direct control.
• Information systems remain weak and fragmented, hindering
timely, efcient, and comprehensive reporting and analysis of spending. Countries can
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
deploy robust, digitalized nancial and health management information systems.
s
Decentralized countries need to scrutinize PFM bottlenecks and tailor politically feasible
reforms to their context, at times embracing paradigm shifts and confronting thorny
governance challenges. The varying needs and capabilities of health system actors will lead
to different policy designs. Where the need for change has yet to gain traction, building
understanding of PFM issues among national and sub-national policy makers is an urgent next
step.
Marie-Jeanne Offosse, ThinkWell, Ouagadougou, Burkina Faso
Burkina Faso’s 1991 Constitution shifted governance in the country from a centralized system
to a devolved structure. It set the stage for the transfer of decision-making authority related
to four sectors including health from the central government to communes, the lowest local
government unit in the country. Yet, three decades later the devolution of substantive and
effective decision-making has yet to be fully implemented.
The aim of this study is to assess Burkina’s readiness for effective health nancing devolution
and highlight public nancial management (PFM) requirements for a successful transition.
We undertook a detailed desk review of the literature on health nancing arrangements,
devolution in the health sector, and PFM systems and practices at different levels of
government in Burkina Faso. Next, we conducted key informant interviews at the national and
commune level.
Key
The bulk of central government resources for health ow from the national government to
public providers and the district health ofces, which function as the local representatives of
the Ministry of Health. In contrast, health spending by communes remains minimal, and is
limited to covering some of the operating costs of public facilities. For example, in 2017, 75% of
Burkina’s health spending occurred at the subnational level, but only 3% of that was controlled
by communes.
Several PFM constraints complicate the transfer for more health resources to communes. For
example, communes are still using line-item budgeting whilst the central government has
moved to program-based budgeting (PBB). Health sector funding transferred to communes
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
will be recorded as government spending for decentralization rather than health expenditure.
More importantly, the lack of accountability structures and safeguard measures for PFM at the
commune-level pose a challenge to ensuring that health spending levels are sustained.
A full transfer of health spending functions to the communes may be inefcient and impede
health workers recruitment in primary health centers. The transfer of health sector payroll to
communes may lead to additional cost for the government and administrative burden for rural
communes given the human resource challenges they face.
s
Devolution of public health expenditure to subnational levels in Burkina Faso appears
challenging owing to weak PFM systems at the commune level. Devolution of health nancing
functions is likely to be partial, implemented in a phased manner. Activities such as payroll
management could remain centrally managed, while all non-wage spending transferred to
communes that adopt PBB.
Salomão Lourenço, ThinkWell, Mozambique
In Mozambique, the decentralization process began in the 1990s, following the opening of the
political arena, under the 1990 Constitution and the end of the civil war. The process is based
on the administrative and scal decentralization under the scope of the 2003 Law on Local
State Bodies and political decentralization in the context of creating local authorities and of the
approval of the decentralization package in 2019 and 2020.
This study explores how decentralization has shaped public nancial management processes
in the health sector in Mozambique.
We collected data through desk review supplemented with insights from health nancing
and policy experts in the country. The desk review entailed a purposeful review of documents
and data that could be accessed online, including from the Government of Mozambique,
international organizations, development assistance projects, and peer-reviewed literature.
When clarications were needed, we consulted health nancing and policy experts.
Key
In 2018, Mozambique’s Constitution was revised to create decentralized bodies at provincial
level. Therefore, there are now two provincial bodies specic to the health sector: the Provincial
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Directorate of Health, the decentralized body, and the Provincial Health Services, the extension
of the national power. This highlights the need for increased coordination between the two
bodies to achieve health targets. Each provincial body develops its own budget. While the
budget of provincial directorates of health is approved by the Provincial Assembly, the budget
of provincial health services is submitted for discussion and approval by the National Assembly.
In parallel, district health ofces develop their own budgets within in the ceilings provided by
provincial ministries of nance. Their budgets are consolidated with provincial health services
budgets for eventual presentation and approval of the National Assembly. This situation
generates bottlenecks in funding of primary care facilities as they fall under the competence of
the decentralized provincial body which sets health priorities. However, primary care facilities
rely on nancing from district health ofces, which are expected to be decentralized in 2024.
Therefore, primary care facilities do not receive enough nancial resource to provide quality
services and to achieve the targets set at provincial level.
s
The decentralization process in Mozambique is not complete. There are often misalignments
between the different subnational government levels, each one with its own budget and
priority interventions. This impacts the way primary care facilities are nanced hampering
service delivery and achievement of health goals.
Gemini Mtei, Abt. Associates Inc., Public Sector Systems Strengthening Plus (PS3+) Project, Dar
es Salaam, Tanzania
In 2017, Tanzania introduced direct facility nancing (DFF) reforms in the disbursement of
health sector basket fund (HSBF) money from the Treasury system. Before, HSBF money was
disbursed to local government authorities (LGAs), which were responsible to plan, budget and
procure inputs for health facilities. Facilities received inputs in kind, which in most cases were
not aligned with community needs. Through DFF, funds were disbursed directly from Treasury
to health facilities’ bank accounts, marking a critical change in the core public nancial
management (PFM) system.
This study documents Tanzania’s experience in the implementation of DFF and highlights the
enabling factors of country-wide implementation, focusing on the extension of PFM systems to
health facilities.
This is a descriptive paper explaining how the extension of PFM systems to health facilities
enabled successful implementation of DFF under a rigid PFM system. The study draws from
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
available literature and the experience of the authors during the process of DFF design and
implementation.
Key
Funds disbursed by Treasury follow strict PFM rules, among which is the requirement to
develop plans and budget and use government nancial management systems for accounting
and reporting. Prior to 2017, these systems were only used up to the level of LGAs, and facilities
were not visible in the PFM system. The introduction of DFF required the extension of planning,
budgeting, and nancial management systems to ensure that use of funds disbursed from
central Treasury directly to facility bank accounts followed PFM rules. This was done through
the revision of the chart of accounts in the electronic planning system (PlanRep) to include
all health facilities’ provider codes, thereby creating space for all facilities to develop their own
plans and budgets. Further, a simple Facility Financial Accounting and Reporting System
(FFARS) was developed to facilitate budget execution at the service provider level. Extending
these systems to facility level helped to build trust that funds disbursed to facilities through a
capitation payment mechanism would be efciently managed within the PFM system.
s
The experience from Tanzania shows it is necessary to build trust within the Treasury system
to be able to implement direct facility nancing. Such trust may be gained by ensuring that
sound planning, budgeting and nancial management system are implemented at health
facility level to ensure efcient management of public funds.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Juliet Nabyonga, World Health Organization, Harare, Zimbabwe, Diane Karenzi
Muhongerwa WHO/AFRO, Brendan Kwesiga, WHO Kenya Country Ofce, Nairobi, Kenya,
Christabell Abewe, WHO Uganda Country Ofce, Kampala, Uganda, Anita Njemo Musiega,
Institute of Healthcare Management, Starthmore University Business School, Nairobi, Kenya.
The COVID-19 pandemic has demonstrated that many health systems are currently not
adequately equipped to anticipate, prevent or mitigate health threats and resulting economic
crises. For countries to respond to COVID-19 and ultimately navigate themselves back to the
path for Universal Health Coverage, there is need for better prioritization of public spending,
both in the immediate and the medium-term. Immediate action is needed to ensure
access to and delivery of the necessary population-based and individual services as part of
the response along with building systems for long term sustainability and accountability.
This requires nancing actions that focus beyond delivering biomedical interventions but
also strengthening (and in some situations establish) core population-based functions as
foundations to support preparedness for health security. Achieving this will require reorienting
budgetary arrangements to; enable the countries to roll out response interventions including
delivery of vaccines, therapeutics, and diagnostics and to sustain the capacity to prevent,
mitigate and respond to health threats in the short, medium, and longer term. While resource
needs have been estimated for COVID-19 response including vaccine roll out, there is a dearth
in information on how (and whether) these have inform budgetary process/budget re-
orientation on adequate nancing response for COVID-19 response and enable preparedness
for future pandemics across health and enabling sectors. This session will focus on answering
the following questions based on country Public Finance Management (PFM) systems and
their experiences/lessons in the response to COVID-19;
What should be nanced?-key functions and budget inputs that need to be prioritized for
both preparedness and response
Who should be nanced?-budget-holding agencies that are responsible for ensuring these
functions are delivered based on the identied funding areas (both health and non-health and
also non state actors)
How should they be nanced? -Fiscal instruments available to nance preparedness and
more broadly capacities to enable health security? Which are feasible and what are their
implications? What changes in budget formulation and execution processes may be needed
to enable the efcient delivery of the key functions in the medium term
How to account for spending and outputs?-Tracking and accountability so that the exibility
required for an agile response does not result into abuse.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Brendan Kwesiga, WHO Kenya Country Ofce, Nairobi, Kenya
In 2013, Kenya implemented scal devolution Kenya as part of new constitutional reforms
from the 2010 constitution. This changed how resources ow through the health system and
who makes decisions on the use of resources. The resulting changes in the Public Finance
Management (PFM) laws also affected how planning and budgeting, budget execution and
accountability, and reporting are done. To examine the effectiveness of ows of resources for
health care services from the national level to health facilities within the counties, we assessed
the predictability and timeliness of funds for health services at government facilities.
The study undertook Public Expenditure Tracking Survey (PETS) which used a mixed-methods
approach. Quantitative data were collected from the national level, a sample of 18 counties,
and 564 health facilities within these sampled counties. Quantitative data were collected for FY
2017/18 and FY 2018/19 with a focus on all health sector resources within the PFM system from
both government and donors.
While all disbursements from the national level were received at the county level, there were
signicant delays in the disbursement of resources from the national to the county level. The
percentage of resources transferred from county to national varied across different grants
based on discretion to reallocate exercised at the county level. For some of the counties,
expenditures were incurred at the county level with almost no funds remitted to the facilities
while in some instances where resources ow to the facilities, there was limited autonomy to
spend. There was an additional delay at this level adding to the delay at the national level. This
was found to affect the ability of the health sector to spend the resources allocated to improve
the delivery of quality health services at the facility level.
Lack of predictability and delays in the ow of resources is likely to limit effective utilization of
the allocated resources. This was a hindrance to Kenya’s response to COVID-19 and is likely to
also affect preparedness for future epidemics.
Christabell Abewe, WHO Uganda Country Ofce, Kampala, Uganda,
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Since the 1990s, Uganda has undertaken various reforms in the way public resources are
budgeted for and utilized to ensure effective management of revenue and expenditure. One
of the most recent reforms that have been undertaken is the transition from output-based
to program-based budgeting through the program-based budgeting (PBB) system where
Ministries and government agencies (MDAs) are supposed to budget according to outcomes.
This is meant to harmonize budgeting within and between MDAs across government. This
study set out to document the experience of transitioning to program-based budgeting in the
health sector in Uganda at both national and sub-national levels.
Data was collected through document review and key informant interviews at the central level
and in 2 districts selected purposively based on their involvement in the rst phase of roll out
of PBB.
The transition to program-based budgeting has been challenging pertaining to the complexity
of the health nancing system and aspects specic to the program-based budgeting
reform hence affecting full alignment with the principles of PBB. When fully implemented,
the objectives of PBB in Uganda can achieve the required budget re-orientation necessary
for effective preparedness and response. However, we nd that there is still pervasive
fragmentation (silos in implementation) and rigidity that hinder effective preparedness and
response. The indicators used for reporting still capture processes and outputs, rather than
outcomes.
Based on the lessons learned in response to COVID-19, there is a need to ensure Uganda’s
health sector transition to PBB emphasizes clear program structures that enable coordinated
government action if the country is to fully realize the potential of this reform.
Anita Njemo Musiega, Institute of Healthcare Management, Starthmore University Business
School, Nairobi, Kenya
Before the COVID-19 global pandemic, Kenya had expressed commitment to Universal Health
Coverage. With the health system disruptions caused by the pandemic, the country has to set
itself on a path to ensure it not only recovers from the current pandemic but also is prepared
for any emergency future outbreaks. One of the key ways of achieving this is understanding
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
how the current Public Finance Management (PFM) systems hindered/enabled the countries’
ability to respond and what needs to be done to address these bottlenecks.
The assessment used both qualitative and quantitative data at both national and sub-national
levels (3 counties) to explore the budget formulation, structure and composition, execution,
and reporting in the context of epidemic response and preparedness.
While health emergencies require an “all of government” approach, who is nanced (budget
holder) and what is nanced (budgetary inputs or even broader programs) was not often
clearly reected in the budgets at the national and sub-national levels. There is also a challenge
in terms of exibility/re-allocation within health programs which limits the agility of a response
to the pandemic. There were also challenges in ensuring accountability in the utilization of
allocated resources.
There is a need to re-orienting budgetary and accountability arrangements to ensure
alignment to the twin agenda of health security and UHC. Countries could utilize the routine
budget dialogues at the national and county levels to transform this ambition into actual
resource allocation decisions.
Juliet Nabyonga, World Health Organization, Harare, Zimbabwe
The Covid-19 pandemic presented an unprecedented health and economic crisis globally.
Given the scale of the pandemic, countries employed several mechanisms to nance the
COVID-19 response including re-allocation away from non-priority areas, the release of
supplementary budgets, and the creation of special extra-budgetary funds. The establishment
of such funds is premised on ensuring an agile response to address existing delays and
rigidities in public nancial management systems. We examined the accountability
mechanisms used in the 22 African countries that reported to have established extra-
budgetary funds as part of their initial response to COVID-19.
Data was obtained from the WHO COVID PFM database which compiled information
generated through a PFM web survey designed and administered in April-May 2020 by WHO
and other primary and secondary sources of information on emergency spending measures,
enactment of spending plans, formulation of spending plans, spending modalities, and
reporting mechanisms). For a review of accountability mechanisms, we focus on; the presence
and nature of the management and oversight structures, and spending and accountability
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
modalities
Fourteen (14) out of the twenty-two (22) countries that allocated extra-budgetary COVID-19
funds did not provide any information on at least one of the three parameters analyzed,
namely the presence and nature of the management and oversight structures, and spending
procedures. The management and oversight of Covid-19 extra-budgetary funds were held by
ministries of health and the treasury in only 3 countries. Eleven countries employed Adhoc
measures including setting up independent committees and structures to manage Covid-19
funds. The lack of explicit transparency and weak oversight given the funds involved and the
scale of the response was reported to have exacerbated fraud and mismanagement of these
public funds. This affected public trust in the government’s response to the pandemic.
Responding to a major pandemic in the context of fragile institutions well as low public
distrust in governments requires strong public nance systems. Lessons learned from setting
up and managing extra-budgetary funds provide an opportunity for an agile response but
require an empowered citizenry and overall good governance if they are to function effectively
in improving the country’s ability to respond.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University of Nigeria, Enugu, Nigeria, Eric Oluedo, University of
Nigeria, Enugu, Eric Obikeze, University of Nigeria, Nsukka, Enugu Campus, Enugu, Nigeria
and Ijeoma Okoronkwo, University of Nigeria, Enugu Campus,, Enugu State, Nigeria
Nigeria’s population prole is characterized by a large informal sector and many poor rural
people. Over 70% of the population lacks nancial risk protection, affecting primarily informal
and rural populations. Community-Based Health Insurance (CBHI) may be an essential
intervention strategy for ensuring that quality healthcare reaches the informal and rural
populations.
This article explores the willingness to enrol and pay for CBHI by community members, their
decision considerations, and associated factors in Enugu state, Nigeria.
We adopted a descriptive cross-sectional survey design. 510 respondents were enlisted with
a multi-stage sampling approach using a validated questionnaire. Willingness to enrol (WTE)
and willingness to pay (WTP) for CBHI was determined using the bid contingent valuation
method. A test of correlation/association (Chi-square and Ordinary Least Square regression)
were conducted to ascertain the relationship between WTP for CBHI and other variables at a
95% condence interval. The Socioeconomic status (SES) index was generated using principal
component analysis (PCA). A test of association was conducted between the demographic
characteristics and WTE and WTP variables.
A total of 501 households were included in the study, yielding a return rate of 98.2%. The
nding showed that most (92.4%) of the respondents indicated a willingness to enrol for CBHI.
86.6% indicated a willingness to pay cash for CBHI, while 84.4% indicated a willingness to pay
for other household members for CBHI. There were signicant association between gender,
marital status, education and location and willingness to pay. 81.6% of the respondent stated
that qualied staff availability motivates their willingness to enrol/pay for CBHI. 78.1% would
be willing to enrol and pay for CBHI if services were provided free, and 324 (74.6%) stated that
proximity to a health facility would encourage them to enrol and pay for the CBHI.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
For equity in health services, concerns by respondents need to be given adequate attention
by the government. The NHIS and ENSUHCA should establish a pool of funds to subsidize and
exempt the poorest and other disadvantaged individuals from enrolling in CBHI. The study
cannot be generalized to all urban areas due to the mixed nature of the LGA in which it was
done.
, World Health Organization, Kampala, Uganda
Everyone has a right to quality life with good health of the household and, thus, health sector
nancing should be a top priority because when the population is healthy, it is very productive
and wealthy. In Uganda, Health Centre IVs (HCIVs) created under Uganda National Minimum
Health Care Package provide curative, prevention and promotion services and thus efciency
of these HCIVs is as critical as people’s health.
To assess efciency in resource utilisation at the lower levels in Uganda based on the fact
that many researches on efciency in Uganda have concentrated on hospitals or tertiary
level of healthcare and thus there is little knowledge on efciency on lower levels and if the
quantitative methods like Data Envelopment Analysis (DEA) can be applied to lower level
facilities.
The study used Hospital and HCIV Census data for 2014 and health sector data for FY2015/16
reported by MOH in the Annual Health Sector Performance Report. STATA software was used
to perform DEA for a preferred model was out-put oriented that optimizes variable returns to
scale and efciency scores for every HCIV were calculated. Also, Tobit regression model was run
to estimate the factors contributing to the adjusted inefciency scores for HCIVs.
Overall, 7 HCIVs (23.3%) were operating under constant returns to scale, implying that they
were efcient (both pure technical and scale efciency) while the 19 (63.3%) were operating
under increasing returns to scale, implying that their health service outputs would increase
by a greater proportion compared to any proportionate increase in health services if more
inputs were added in the facility. Four HCIVs (13.3%) were operating at decreasing returns to
scale meaning an additional input to the HCIVs would produce a less proportional change of
outputs. The study identied catchment population, average length of stay, bed occupancy
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
rate, and outpatient department visits as a proportion of inpatient days as the main factors of
efciency among HCIVs.
This study has shown how DEA methods can be applied at the HCIV level of the health system
to gain an insight into variation in efciency across health centres using routinely available
data. And, with the majority of HCIVs operating at increasing returns to scale, it showed that
there is a need to increase inputs like staff, medicines and beds to achieve the desired optimal
scale in case of constant returns to scale.
1, Edwine Barasa1, Kara Hanson2, Lizah Nyawira1, Andrew Mulwa3, Sassy
Molyneux4, Isabel W Maina5, Benjamin Tsofa4, Charles Normand6 and Julie Jemutai4, (1)Health
Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya, (2)
London School of Hygiene and Tropical Medicine, London, United Kingdom, (3)Council of
Governors, (4)KEMRI-Wellcome Trust Research Programme, Kili, Kenya, (5)Ministry of Health,
Nairobi, Kenya, (6)University of Dublin
Improving health system efciency is a key strategy to increase health system performance
and accelerate progress towards Universal Health Coverage. In 2013, Kenya transitioned into a
devolved system of government granting county governments autonomy over budgets and
priorities. We assessed the level and determinants of technical efciency of the 47 county
health systems in Kenya.
We carried out a two-stage data envelopment analysis (DEA) using Simar and Wilson’s double
bootstrap method using data from all the 47 counties in Kenya. In the rst stage, we derived
the bootstrapped DEA scores using an output orientation. We used three input variables
(Public county health expenditure, Private county health expenditure, number of healthcare
facilities), and one outcome variable (Disability Adjusted Life Years) using 2018 data. In the
second stage, the bias corrected technical inefciency scores were regressed against 14
exogenous factors using a bootstrapped truncated regression.
The mean bias-corrected technical efciency score of the 47 counties was 69.72% (95%CI
66.41-73.01%), indicating that on average, county health systems could increase their outputs
by 30.28% at the same level of inputs. County technical efciency scores ranged from 42.69%
(95% CI 38.11%-45.26%) to 91.99% (95% CI 83.78%-98.95%). Higher HIV prevalence was associated
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
with greater technical inefciency of county health systems, while higher population density,
county absorption of development budgets, and quality of care provided by healthcare
facilities were associated with lower county health system inefciency.
The ndings from this analysis highlight the need for county health departments to
consider ways to improve the efciency of county health systems. Approaches could include
prioritizing resources to interventions that will reduce high chronic disease burden, lling
structural quality gaps, implementing interventions to improve process quality, identifying the
challenges to absorption rates and reforming public nance management systems to enhance
their efciency.
1, Clara Affun-Adegbulu2, Kirsten Accoe2, Remco van de Pas2,
Vanessa Pridith Noukoudodji Tohoubi3 and Bruno Marchal2, (1)Centre de Recherche en
Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Benin, (2)Institute of
Tropical Medicine (ITM), Antwerp, Belgium, (3)Conseil National de Lutte contre le VIH/Sida,
la Tuberculose, le Paludisme, les Hépatites, les Infections Sexuellement Transmissibles et les
Epidémies (CNLS-TP), Cotonou, Benin
Community health workers (CHW) are effective in alleviating the global
challenge of health workforce shortage. They contribute to improve health outcomes and
access to care. Scaling up CHW programmes is a key step on the pathway towards universal
health coverage (UHC), especially in low and middle-income countries such as Benin.
This work analyses the Benin’s 2020-2024 National Community Health Policy
(NCHP), and identies and addresses potential challenges which may hamper its proper
implementation.
We deductively analysed the newly designed community health system of Benin,
and specically its community health workforce, through a document review, using as
framework, respectively the Institute of Tropical Medicine (ITM) Health System Dynamics
Framework and the Community Health Worker Assessment Improvement Matrix (CHW AIM).
The analyses was highly informed by the “WHO guideline on health policy and system support
to optimize community health worker programmes”.
According to the new NCHP, the governance and the functioning of the community
health system is ensured through a multisectoral collaboration, based on the “One Health”
approach. A “Local Component of the Health System” (CoLoSS) is intended to be the extension
of the health system in each village or neighbourhood, and to provide a space for effective
community participation.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Regarding the workforce, the NCHP designated two CHW cadres: the qualied community
health agent (ASCQ) and the community relay (RC). Both of them are intended to be
integrated into the overall health workforce, with formal remunerations. However, there is no
institutional or legal basis to support the CHW formal status. In addition, RCs are selected from
their community where they should provide promotional and preventive care through home
visits, community outreaches and campaigns. The ASCQ, covering each arrondissement, is
a skilled health worker who supports and supervises RCs under his/her responsibilities and
provides rst-line curative care at a post.
Some potential implementation challenges have been identied, with specic
recommendations to help to overcome them. One important challenge is related to the
sustainability of the programme, requiring a strong political and nancial commitment from
the government. Other challenges concern the non-optimal workload for CHWs and their
unclear training process, which may impede their performance and long-term retention.
The new NCHP of Benin is ambitious and promising in its design, and could help
to effectively improve population health outcomes, if the identied challenges are early and
adequately addressed.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Academic and Career Development Initiative
Cameroon (ACADI), Bamenda, Cameroon
The year 2015 marked a key turning point in the global development agenda, as the UN
General Assembly on 25 September 2015 adopted the Sustainable Development Goals
(SDGs), aimed at inducing inclusive and sustainable development in member states towards
overcoming the limitations of the Millennium Development Goals (MDGs) viz. a limited
focus, resulting in verticalization of health and disease programmes, a lack of attention to
strengthening health systems, the emphasis on a “one-size-ts-all” development planning
approach, and a focus on aggregate targets rather than equity. The SDGs comprise 17 goals
and 169 targets, including one specic goal for health with 13 targets, to wit: “Ensure healthy
lives and promote well-being for all at all ages.” SDG 3.8 states: “Achieve universal health
coverage, including nancial risk protection, access to quality essential health-care services
and access to safe, effective, quality and affordable essential medicines and vaccines for all.”
Paragraph 26 of the 2030 agenda addresses health as follows: “To promote physical and
mental health and wellbeing, and to extend life expectancy for all, we must achieve universal
health coverage and access to quality health care. No one must be left behind. We commit to
accelerating the progress made to date in reducing newborn, child and maternal mortality
by ending all such preventable deaths before 2030... We will equally accelerate the pace
of progress made in ghting malaria, HIV/AIDS, tuberculosis, hepatitis, Ebola and other
communicable diseases and epidemics, including by addressing growing antimicrobial
resistance and the problem of unattended diseases affecting developing countries. We
are committed to the prevention and treatment of noncommunicable diseases, including
behavioural, developmental and neurological disorders, which constitute a major challenge
for sustainable development.”
Universal health coverage (UHC), is the vehicle adopted for the implementation of the broad
and ambitious health agenda in all countries. It is necessary that policy makers integrate
Primary Health Care in the global discourse towards guaranteeing the achievement of the
SDG targets, considering observations made from the local context of the Cameroon health
system. The author believes that Comprehensive Primary Health Care remains a valuable and
integrated approach that could guarantee the health of all populations universally, not merely
a concept to be neglected, as it has been the case during the last two decades.
Primary health care, Universal health coverage, Health system strengthening, SDG,
Community health, Access, Equity
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Obinna Onwujekwe2, Prince Agwu3, Pamela Ogbozor4, Tochukwu Orjiakor5,
Eleanor Hutchinson6 and Dina Balabanova6, (1)University of Nigeria, Nsukka, Nsukka, Enugu,
Nigeria, (2)University of Nigeria, Nsukka, Enugu Campus, Enugu, Nigeria, (3)University
of Nigeria, Nsukka, Nsukka, United Kingdom, (4)Enugu State University of Science and
Technology, (5)University of Nigeria, Nsukka, (6)The London School of Hygiene & Tropical
Medicine
Healthcare facilities are routinely regarded as fundamentally an institution or establishments
housing local medical services or practices. In that sense, the enduring human interactions
and economic transactions in these spaces are often overlooked. Yet, this could pose challenge
to healthcare delivery and the overall intent to meet health-related goals.
In this study, we narrate how health facilities operate like a marketplace, and drew attention
to its implication to healthcare delivery. Our description of marketplace follows an economic
anthropological perspective, which see them as sites for complex social processes, instigators
of cultural activity and realms for economic exchange.
The study was based on eight weeks of observations of six Primary Health Centres (PHCs) and
two local government headquarters by four eldworkers in Enugu State, Nigeria. The data was
supplemented with semi-structured interviews with health workers, service users, and health
managers. The data were analysed using NVivo, and followed a narrative analytical approach.
The narrative showcases that health facilities are not just centres for health delivery but
are hubs for economic activities, intertwined with social and cultural processes that in turn
affect access to care. Beside pharmaceutical products, snacks, wears and drinks are sold by
marketers and health workers on duty within the premises. Sometimes, this interfere with care
when health workers absent from duty to attend to their private business. Our narrative also
demonstrated that access to pharmaceutical products as well as other medical services can
be inuenced by social relations and perceived ability to pay while services that are free can
be offered for a fee. These activities were made possible by weak institutional structures that
hardly communicate policies or regulate health workers’ activities.
The study concludes that beside serving as a centre for healthcare delivery, health facilities also
sustain social and economic activities which sometimes interfere with service delivery. Health
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
managers must manage informal structures within this space to improve health care delivery.
Marketplace, Primary Health Centres, Economic, Absenteeism, Informal payment.
1, Audrey Mumbi2, Precious Kilimo3, Jessica Vernon3 and Edwine Barasa1, (1)
Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi,
Kenya, (2)Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, (3)
Maisha Meds
The COVID-19 pandemic has increased the global morbidity, mortality, social and economic
burden. While most developed countries have made progress in developing vaccines and
vaccinating their citizens, developing countries such as Kenya still struggle with ensuring
the whole population can access COVID-19 testing with existing testing approaches being
either too expensive, inaccessible or both. Pharmacy-based testing of COVID-19 is an essential
component of the response strategy. However, it is not clear how much people would be
willing to pay for such approaches in Kenya. This study examined the level and correlates of the
willingness to pay (WTP) for rapid COVID-19 testing delivered through private retail pharmacies
in Kenya.
We conducted a cross-sectional double-bounded dichotomous choice contingent valuation
survey across 341 clients visiting ve private retail pharmacies in Nairobi, Kisumu and Siaya
counties in Kenya. We computed the mean and median WTP, demand curves alongside the
correlates of WTP.
Our results indicate a mean WTP of KES 611 (US$ 5.5) (95% CI: 418 – 666) and a median WTP
of KES 506 (US$ 4.6) (95% CI: 385 – 572). Furthermore, the study shows that the client’s WTP
increased with household income and interest in getting the COVID-19 test at a private retail
pharmacy.
These ndings provide some insights into the price setting for COVID-19 testing delivered
through private retail pharmacies in Kenya. This analysis emphasizes the role of private-retail
pharmacies in extending the COVID-19 testing capacity in Kenya and the utility of clients’
WTP in price setting. Policymakers and other actors can adopt these estimates to design and
implement subsidization and adequate price setting that takes into account clients’ WTP
which could enhance COVID-19 testing uptake in Kenya.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University of Ghana School of Public Health, Accra, Ghana and
Lucy Gilson, University of Cape Town, South Africa
Low-and-middle-income countries (LMICs) responded to the Alma Ata
declaration on Primary Health Care (PHC) by adopting community-based strategies.
The implementation of these strategies has largely remained poor. Myriad of factors in
management and utilization of the services have been attributed to the implementation
challenges. Far less attention has been paid to the actors involved in the implementation, the
networks they form through their interactions and the roles these networks play, either as
barriers or enablers in the implementation process. However, implementation of PHC require
the working with and through set of actors or networks and across relations to communicate
policy objectives, paying attention to the actors’ interests and the structured relationships
between them. This scoping review sought to identify actor networks and their roles in PHC
implementation in LMICs and also \to understand from existing experience how networks add
to our understanding of implementation processes.
The study followed the ve-stage scoping review methodological framework by
Arksey and O’Malley. We searched four bibliographic databases to identify all relevant scholarly
and gray primary research studies reported in the English language, regardless of publication
status and with no date limits. We also searched reference lists, and hand searched selected
journals and websites. To be eligible for the review, primary studies had to describe and report
the results that determined relationship between networks (actor networks) or social networks
and any aspect of PHC in LMICs. All references were exported to Mendeley library. Title and
abstract screening were carried out and duplicates were removed. Narrative synthesis was
applied to describe the included studies and the results.
We identied 13 primary studies. The different papers examined different networks.
Ten different networks types were identied: professional support networks, friendship
networks, referral networks, inter-sectoral collaboration networks, community health
committee networks, peer networks, health coordination and emergency referral networks,
partnership networks, inter-organizational networks and communication networks.
Professional advice networks of healthcare workers in PHC units were observed to provide
better change in health provider practices; peer networks increase the probability of early
antenatal check-up and antenatal completion. It was also observed that intersectoral
collaboration networks enhance organization’s ability to serve as gatekeepers of information
and communication networks enhance the ow of information among PHC implementers.
Our review provides evidence that relational elements such as networks exist and
they inuence PHC implementation in LMICs. Leveraging actor networks in PHC could drive its
effective implementation in LMICs.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Centre de Recherche en Reproduction Humaine et en Démographie
(CERRHUD), Cotonou, Benin, Jan De Lepeleire, KU Leuven - University of Leuven, Leuven,
Belgium, Ludwig Apers, Institute of Tropical Medicine, Antwerp, Belgium, Djimon Marcel
Zannou, Université d’Abomey Calavi, Faculté des Sciences de la Santé, Cotonou, Benin and
Bart Criel, Institute of Tropical Medicine, Antwerp, Antwerp, Belgium
COVID-19 is challenging African health systems, particularly the rst line of healthcare, which
is responsible for operationalizing much of primary health care. This paper analyzes the
experience of physicians working at this level of the system and draws lessons for improving
primary health care.
We conducted a mixed-method, sequential, explanatory study between April and July 2020.
Quantitative data were collected from 90 primary care physicians (PCPs) in four health districts
in Benin. We performed descriptive and bivariate analyses on these data. We then conducted
thematic content analysis on the qualitative data, collected from 14 PCPs. Quantitative and
qualitative results were triangulated.
According to the PCPs, their health facilities had implemented 74.8% of the COVID-19’s control
measures, with no signicant difference between the public and private sectors. However,
several important measures were poorly implemented. In addition, only 54.7% of the PCPs
felt condent to manage a suspected case of COVID-19 effectively, with a lower proportion in
the private sector. While 80.2% of PCPs reported being stressed, only one-quarter reported
receiving adequate support from local health authorities. This support appeared to be weaker
for private PCPs. Finally, almost three-quarters of the PCPs stated that the pandemic had
reduced service attendance and impacted their daily work. There were negative impacts such
as decreased quality of care or decreased availability of services. But there were also positives
points such as innovations to maintain the essential services, strategies to reduce costs for the
patients, and the role PCPs played in strengthening the capacities of the non-medical primary
care workforce.
Our results reminded the need to improve the primary health care organization in our settings.
Indeed, the pandemic seems to have exacerbated existing dysfunctions such as the low quality
of care or the absence of a structured mechanism to support health workers, especially in the
private sector. However, the study also showed several opportunities. If properly utilized, these
opportunities could constitute levers for action to strengthen primary health care.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University of Nigeria Enugu Campus, Enugu, Nigeria
Authors: Ughasoro D. Maduka 1, Eze N Joy 1, Oguonu Tagbo1, Onwujekwe Obinna Emmanuel2
A better representation of the burden of childhood asthma should rely on both
morbidity and mortality, not only mortality. This will reduce the dearth of information on
burden of childhood asthma, and enhances evidence-based decision-making. In this study,
burden of childhood asthma was estimated, using disability-adjusted-life-years (DALYs),
factoring in the disability weights for asthma, age at mortality and life expectancy.
The study was conducted at the University of Nigeria Teaching Hospital, Enugu.
Interviewer administered questionnaire was used to collect information from parents of
children with asthma who presented to respiratory clinic on: the level of their asthma control
(controlled, partially controlled and poorly controlled asthma), their age distributions, and sex.
The prevalence of asthma, prevalence of associated disability, and case-fatality were obtained
from previous publications. The DALYs were estimated by adding together the years lost to
disability (YLDs) and years lost to life (YLLs) to asthma (DALYs = YLD + YLL). DALYs were dis-
aggregated by age group and by whether their asthma were controlled, partially controlled
and poorly controlled.
A total of 66 children with asthma were studied. The proportion of the subjects with
controlled, Partially controlled and poorly controlled asthma were 26 (39.4%), 31 (47%), and
9 (13.6%) respectively. The subjects that have some form of asthma-related disability were
16 (24.3%). The childhood asthma caused 23.6 to 34.24 YLLs per 1000 population, 0.01 to 1.28
YLDs per 1000 population and 24.23 to 34.41 DALY per 1000 population. There was minimal
difference in DALYs across the three clinical categories, but was consistently higher among
older children 12 to 17 year. The estimated national DALYs was 407,820.2 about of 1.6% of the
global all age (children and adults) DALYs of 24.8 million.
The DALYs due to childhood asthma was high and did not vary much across the
clinical categories, but increased with age. This imperatively necessitates the de-emphasis
on just clinical responses as an indicator of the efciency of childhood asthma control
interventions but rather a holistic approach should be adopted considering the limitations the
child suffer as component of both life and environmental modication in a deliberate attempt
to prevent attacks. The ability of the child to function optimally while on treatment should be
considered in the treatment impact review.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Hannah Marker2, Mahamoudou Touré3, Mark McGovern4, Hamadoun Sangho3,
Peter Winch2, Joshua Yukich5 and Seydou Doumbia3, (1)National Institute of Public Health
(INSP) and University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako,
Mali, (2)Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, (3)
University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali, (4)
Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway,
(5)Tulane University, New Orleans, United-States
Malaria remains a global priority, with 229 million cases worldwide in 2019. Several
promising strategies are being implemented to ght malaria, including seasonal malaria
chemoprevention (SMC). SMC is typically administered to children under ve years of age,
however, few previous studies have considered the impact of extending this to other age
groups. We assessed the effectiveness of extending SMC to children under 10, and the potential
externalities of treating this age group on younger children.
We conducted a quasi-experimental difference-in-differences evaluation of an SMC
intervention in Mali in 2020. Three control villages in Koulikoro received standard treatment
with SMC given to children aged 0-4, while six intervention villages received SMC treatment
for children aged 0-9. In regression analyses of outcomes for 6,908 children, we compared
differences in the presence of malaria blood parasites between treatment and control villages
using rapid diagnostic tests, before and after the intervention.
Prevalence of malaria parasites were substantially reduced in intervention villages compared to
control villages after the intervention, with an odds ratio for the presence of any blood parasites
in a rapid test of 0.23 (95% CI .08 - 0.63). We found some evidence of externality effects among
younger children with a similar, albeit less precisely estimated, reduction in parasites for
those under ve in villages where children over ve received treatment. Although we did not
measure it in this study, treating young children with SMC may also have positive externalities
for adult members of the community, through reduction of the number of gametocyte carriers
in the community.
Extending SMC to older children is a promising approach for helping achieve global malaria
eradication, especially given the positive externalities we document in this paper. Research
should assess cost-effectiveness to examine feasibility of scaling up future interventions.
Seasonal malaria chemoprevention (SMC), quasi-experimental methods, difference-
in-differences methods, health externalities, child health, Mali.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Hyeladzira Garnvwa and Sarah Martin, National Primary Health Care
Development Agency (NPHCDA), Abuja, Nigeria
To analyse the effects of the COVID-19 outbreak on essential health services in Nigeria,
examining how the pandemic impacted the delivery and utilisation of maternal and child
health (MCH) services within the country. Understanding the extent to which MCH services
have been affected can help guide policy makers in responding to future shocks, especially in
policies to maintain essential services.
Prior to the pandemic, MCH indices in Nigeria were poor. The COVID-19 pandemic further
threatened these services as it impacted the availability of essential health care, as well as the
health seeking behaviours for both emergency and preventive care. Understanding the direct
and indirect impact of COVID-19 on essential health services can help guide policymakers in
building back more resilient health systems and help to better respond to future pandemics
and future health crises.
National quantitative data from the DHIS2 Platform was used to analyse monthly service
utilisation data from select primary health care facilities, focussing on several key MCH services
(deliveries; pre- and post-natal checks; diagnosis and treatment of key illnesses malaria, HIV,
TB; child vaccinations; nutrition and family planning services). This data was used to analyse
changes in essential health care service indicators both before and after COVID-19 outbreak to
understand how the pandemic has affected service delivery.
Analysis of trends in utilisation of essential health services across Nigeria were undertaken, to
shed light on which MCH services were most disrupted by the pandemic. The magnitude of
disruption to service delivery compared to pre-COVID trends were examined, in comparison
to trends in previous years. Further analysis of the service utilisation in rural areas compared
with urban areas was undertaken. The effect of COVID-19 on the structure of health care
delivery was also examined, such as the trends in the nature and location of service delivery, to
understand the changes in facility-based, outreach and home deliveries preferences.
The ndings from the study can be used to inform policy decisions which will contribute to
more resilient health systems following the impact of COVID-19. The study further discusses
methods to strengthen the PHC system to be more prepared to provide and maintain MCH
services in the face of future pandemics, as well as improve the response to future health
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
crises, calling for more research on how to identify and mitigate the causes of falling MCH
service utilisation in the future.
, University of Nigeria, ENUGU, Nigeria and Uta Lehmann, University of Western
Cape, Cape Town, South Africa
Nigeria became a federation in 1954 and currently administratively decentralized into the
national level, mid level 36 states & federal capaital territory (FCT) and 774 local governments
(lower level). Healthcare is a constitutionally concurrent responsibility of the three levels,
however specic roles and responsibilities are not constitutionally prescribed. Governance
arrangements, level of inter-governmental collaboration, actors and implementation
context, inuence subnational policy adoption and implementation of national policies.
States as federating units can adopt, re-shape or reject national policies and can also make
state level policies. This study historically (2007-2019) explores three national programmes
of the integrated maternal, neonatal and child health (IMNCH) strategy, which had inter-
governmental collaborative aspirations within the outlined multilevel governance (MLG)
structure.
This study was in a national setting (Abuja-FCT) and two sub-national (Anambra and Ebonyi
states) in the southeast zone. MNCH burden varies across the country, underpinned by cultural
and socio-economic differences. A qualitative case study design was employed, triangulating
information from documents (69) and in-depth interviews (44), to produce a description of
ndings. Data was organised and coded with NVivo 11. Analysis was guided by the Integrated
Collaborative Governance (CG) framework. System context and drivers (leadership, uncertainty,
interdependence & incentives) generate collaboration dynamics (joint capacity, shared
motivation & principled engagement) which interact iteratively to generate collaborative
actions. Collaboration dynamics and actions make up a CG Regime (CGR).
The key collaborative activity (signing of and committing to MOUs) was not honoured during
implementation, in both study states, despite MNCH contextual variations. Leadership
and incentives were not adequately distributed to span collaborative boundaries despite a
constitutionally determined interdependence of the governance levels. Actor power practices
were predominantly contestations rather than collaborative. This was underpinned by the
existing governance structure. First two programmes were not adequately collaborative to
ensure collaborative action and outcomes. Lessons learnt contributed to a different design
of the third programme, which was more consultative of sub-national stakeholders but
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
implementation was also undermined by the subnational governance structure.
CG brings stakeholders to engage in con-census oriented decision-making. Dialogues, trust
building, commitment and shared understanding are crucial, to overcome conict and
contestations and enable collaborative actions. Hence, a CGR was not achieved. We however,
note that CG has high transaction costs (time and resources), and not easily attainable in
Nigeria and other LMICs with weak health systems. This study proposes an interim structure of
Coordination and Cooperation in these contexts.
, Health Economics Unit, University of Cape Town and John Ataguba,
University of Cape Town, Cape Town, South Africa
Although many countries are making progress towards achieving the global sustainable
development goals, sub-Saharan Africa (SSA) lags behind. SSA bears a relatively higher
burden of maternal morbidity and mortality than other regions despite existing cost-
effective interventions. This paper assesses antenatal care (ANC) service utilisation among
women in the Southern African Development Community (SADC) countries, one of the
four SSA regions. Specically, it assesses socioeconomic inequality in the number of ANC
visits, use of no ANC service, between one and three ANC visits and at least four ANC visits,
previously recommended by the World Health Organization (WHO). Data come from the most
recent Demographic and Health Surveys in twelve SADC countries. Wagstaff’s normalised
concentration index (CI) was used to assess socioeconomic inequalities. Factors explaining
these inequalities were assessed using a standard method and similar variables contained
in the DHS data. A positive CI means that the variable of interest is concentrated among
wealthier women, while a negative CI signied the opposite. The paper found that wealthier
women in the SADC countries are generally more likely to have more ANC visits than their
poorer counterparts. Apart from Zambia, the CIs were positive for inequalities in at least 4 ANC
visits and negative for between 1 and 3 ANC visits. Poorer women are signicantly more likely
to report no ANC visits than wealthier women. Apart from the portion that was not explainable
due to limitations in the variables included in the model, critical social determinants of health,
including wealth, education and the number of children, explain socioeconomic inequalities
in ANC coverage in SADC. A vital policy consideration is not to leave any woman behind.
Therefore, addressing critical social determinants explaining inequalities in ANC utilisation,
such as women’s education and economic well-being, can potentially redress inequalities in
ANC coverage in the SADC region.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Christopher Smith2, Richard
Wachepa2, Hlulose Chafuwa2, James Meiring2, Patrick Noah1, Pratiksha Patel2, Priyanka Patel2,
Fréderic Debullut3, Clint Pecenka3, Melita Gordon4 and Naor Bar-Zeev5, (1)Kamuzu University
of Health Sciences, Blantyre, Malawi, (2)Malawi Liverpool Wellcome Research Programme,
Blantyre, Malawi, (3)PATH, Seattle, WA, (4)Institute of Infection, Veterinary and Ecological
Sciences, University of Liverpool, Liverpool, United Kingdom, (5)International Vaccine Access
Center, Department of International Health, Bloomberg School of Public Health, Johns
Hopkins University, Baltimore MD
Typhoid fever causes high morbidity and mortality in low- and middle-income countries. The
World Health Organization recommends introduction of typhoid conjugate vaccine (TCV) into
countries with high incidence of disease or high burden of antimicrobial-resistant Salmonella
Typhi (S. Typhi). Data on disease burden, cost of illness, delivery costs, and cost-effectiveness
are crucial to inform decisions on TCV introduction. We estimated the household and
healthcare economic burden of typhoid fever in Blantyre, Malawi.
A prospective facility-based costing cohort study was undertaken at two large government
primary healthcare facilities, and a referral district hospital. Household illness costs consisted
of direct medical, direct non-medical, and indirect costs borne by blood culture-conrmed
typhoid fever patients and their families. Healthcare provider costs were the total direct
medical and non-medical costs of managing a conrmed case of typhoid fever at the three
health facilities. Mean costs, in 2020 U.S. dollars, were reported separately for outpatients and
inpatients.
From July 2019 through March 2020, of 109 patients presenting with culture-conrmed S.
Typhi, 63 (58%) were less than 15 years old and 44 (40%) were admitted to hospital. The mean
length of hospitalization was 7.7 days (standard deviation 4.1). For inpatients, the mean total
household and healthcare provider costs were $93.85 (95% Condence Interval (CI): 68.87,
118.84) and $296.52 (95%CI: 225.79, 367.25), respectively. For outpatients, these costs were
$19.05 (95%CI: 4.38, 33.71) and $39.65 (95%CI: 33.93, 45.39), respectively. Direct medical costs for
households were low. Since care is free at government healthcare facilities, the cost burden for
households was due mainly to direct non-medical and indirect costs. Catastrophic illness cost,
dened as cost > 40% of non-food monthly household expenditure, occurred in 48 (44%) case-
containing households.
Typhoid fever and its sequalae can be catastrophic for families, causing major economic
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
hardship despite widely available free medical care. Typhoid is also costly for government
healthcare provision. These data make an economic case for TCV introduction in Malawi and
the region and will be further used to more fully dene vaccine cost-effectiveness.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
and Olajide Sobande, Health Policy Plus (HP+), Lagos, Nigeria
Lagos State located in South West Nigeria is a cosmopolitan state with an informal sector
economy estimated to account for 65% of the working population and approximately 42
percent of the economic activities in the State. This portrays the relevance of the sector in the
journey to achieve universal coverage. This rapid assessment was conducted to understand
the drivers of the limited enrolment of the informal sector groups on the Lagos State Health
scheme (LSHS) and proffer recommendations for addressing the challenges to expansion of
informal sector enrolment on the Lagos State Health Scheme.
We conducted key informant interviews with complimentary desk reviews. Key informants
were purposively selected based on their expertise and experience with informal sector
enrollment and included program managers from the State Health Management Agency
(LASHMA) and implementing partner organizations. The interviews captured how respondents
understood the current challenges of expansion for informal sector enrollment. Interviews
were conducted in English using interview guides. Audio recordings were transcribed, cleaned,
and reviewed for quality purposes. Interviews were coded and analyzed to identify themes
bordering on challenges to informal sector enrollment.
The demand side challenges include the inadequate enforcement of the mandatory nature
of the scheme due to weak regulation capacity, inadequate mobilization of trade associations
due to the existence of multiple umbrella bodies requiring multiple engagements with
attendant human resource and administrative costs, affordability of premiums, socio-cultural
factors such as risk perception for ill health and religious beliefs about health insurance. The
supply side challenges include perceived poor quality of care, unattractive tariffs and limited
benets package
This will include the implementations of strategies to include on the demand side, capacity
building for the regulation arm of the state health insurance agency, targeting the informal
non-poor through mandates for health insurance enrollment as a pre-requisite for access
to public services such as tax permits, business registrations, strengthening of affordability
arrangements through installment payment of premiums, behavior communication to
address socio-cultural beliefs, advocacy for more government funding to cover the poor and
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
vulnerable in the informal sector. On the supply side, improve quality of care and operationalize
performance-based payments/ incentives and disincentives for quality, increase patient voice
by engaging and utilizing civil society organizations (CSOs) as patient advocates, strengthen
existing complaint redress mechanisms for enrollees taking into cognizance the educational
levels and preferences of enrollees for reporting service experience.
challenge, enrollment, informal, health insurance
1, Richard Ssempala2, Moses Tetui2 and Chrispus Mayora1, (1)School of
Public Health, College of Health Sciences, Makerere University, Kampala, Uganda, (2)Makerere
University School of Public Health, Kampala, Uganda
Aloysius Ssennyonjo 1, Richard Ssempala1 Moses Tetui1, and Chrispus Mayora1.
• Department of Health Policy Planning and Management Makerere University School of
Public Health, Kampala- Uganda
In response to the COVID-19 pandemic, the World Health Organisation, other global health
actors and national governments adopted control measures to reduce the virus’s spread
and its impacts. The COVID-19 pandemic rose against a backdrop of global development
efforts towards universal health coverage (UHC). However, previous analyses highlighted that
contextual, health systems, and design issues facilitate or constrain successful UHC reforms.
This study aimed to establish the effects of the COVID-19 pandemic on Uganda’s social
protection context and its implication on designing and implementing the national health
insurance schemes (NHIS) -a major UHC intervention in the country.
Desk review of key government documents and published and unpublished literature was
conducted. Content analysis was undertaken.
Regarding social protection, the COVID-19 crisis exposed and exacerbated the vulnerabilities
of some population groups such as informal workers and urban poor that have often been
less visible. The COVID-19 related lockdowns negatively affected business operations and the
general revenue collections for the country. Other effects included increased unemployment
among formal and informal workers. Health systems-related effects included disruption of
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
health services delivery, adoption of new health insurance policies by some private health
insurances, and nancial risk protection mechanisms to enable the population to access
health care, particularly prevention, testing, and treatment services. New social protection
initiatives such as providing food supplies to vulnerable groups, especially in urban areas, were
established. The COVID-19 pandemic demonstrated the weaknesses and risks of linking the
NHIS enrolment and benets to formal employment. Policy implications included deliberate
considerations for the inclusion of vulnerable groups and harnessing the private sector’s
contributions.
The COVID-19 pandemic led to unprecedented challenges and opportunities for UHC related
policy reforms. Uganda and similar countries should reconsider the role of NHIS in advancing
health system goals in the short to the medium term. Integrating and repositioning the NHIS
into the expanding social protection agenda will be crucial.
Covid-19, Social Protection, UHC, National Health Insurance Scheme, Uganda.
, Nkata Chuku, Oluwatosin Kolade, Emmanuel Ndenor Sambo and
Kingsley Adimabua, Health Systems Consult Limited, Abuja, Nigeria
Lagos state government has commenced implementation of the state social health insurance
scheme as a pathway for universal health coverage for residents of the state - estimated at
25million. Until recently, the benet package of the scheme covered most maternal and child
health services, but family Planning (FP) services were excluded, limited to only counselling.
Evidence from other countries showed that access to and increase in FP services is key to
improving overall health indices, reduce pressure on health systems and drive economic
growth.
This paper presents the pathway which led to the successful integration of the full
complement of FP services into the Lagos State Health Scheme (LSHS)- Ilera Eko.
The integration pathway was developed as an output of benchmark reviews conducted to
glean learnings from other countries, key informant interviews with relevant state actors, and
series of brainstorming sessions with relevant stakeholders working in the eld of FP within
the state.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
We designed a 4-stage integration pathway which include advocacy and stakeholder
management; acceleration of FP readiness in all LSHS empanelled facilities; health benet
package review and actuarial analysis, and full integration. The result of the actuarial study
showed no signicant additional cost to the premium for the proposed integration which
led to inclusion of modern FP methods into the benet package of the LSHS. Factors that
aided the success of the integration plan are buy-in from relevant state agencies, donors,
stakeholders, and State political leadership. A sustainable FP supply chain system for public
and private providers will ensure uninterrupted supply of commodities across all facility types.
It is expected that the integration and mainstreaming of FP services into the LSHS will increase
the state’s Contraceptive Prevalence Rate with increased access and uptake of modern
contraceptive methods. This will yield signicant health benets for women and children,
averting unintended pregnancies, and reducing maternal and infant deaths. In addition, it will
result in cost savings on Maternal and newborn health, while women and girls will be better
able to pursue education, get paid job, increase their earning potential, and build household
savings. These will in turn translate into a stronger and more prosperous society.
1, Espilidon Tumukurate2, Collins Kityo3, Gideon Olaja2, Tapley Jordanwood4,
Michael Chaitkin5, Angellah Irene Nakyanzi6 and Sarah Byakika1, (1)Ministry of Health, Uganda,
(2)ThinkWell Uganda, (3)Ministry of Finance, Planning and Economic Development, Uganda,
(4)ThinkWell USA, (5)ThinkWell, Kampala, Uganda, (6)ThinkWell Uganda, Kampala, Uganda
The Uganda Intergovernmental Fiscal Transfers (UgIFT) Program for is led by the
Ministry of Finance, Planning and Economic Development (MOFPED), with funding from
the Government of Uganda and World Bank, to ensure adequate nancing for and equitable
access to public services. Under UgIFT, the Government of Uganda is working to institutionalize
results-based nancing (RBF) within public purchasing of primary health care services. Thanks
to funding from the World Bank and USAID, all public and private not-for-prot Health Centres
III and IV and General and Regional Hospitals currently participate in RBF.
This study shares insights from Uganda’s experience transitioning from a project-based
RBF scheme to one embedded in the country’s routine public nancial management
and intergovernmental scal transfer systems. It describes how lessons from initial RBF
implementation are informing the development of a mainstreaming strategy, as well as reect
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
on ongoing policy discussions related to sustainability and performance management. Finally,
it highlights key features of the mainstreaming strategy and how RBF will be implemented
within government systems.
All data came from ofcial and draft policy documents and the authors’ recollections
and personal records. All contributing authors were directly involved in the review of
RBF performance and experiences during project mode and the development of the
mainstreaming strategy and accompanying operational manual.
Promising results across a range of monitoring indicators—including ANC attendance,
availability, availability of caesarean section, client satisfaction, quality, and community
participation in facility governance—motivated policy makers to institutionalize RBF within
government systems. A Ministry of Health–led consultative process was undertaken to take
stock of RBF experiences across the country, extract lessons, and develop a mainstreaming
strategy and operational guidelines. Key features of the strategy include embedding RBF
nancial planning in the national budget cycle; redesigning intergovernmental grants for
PHC to include an enhanced base fund and a variable performance-linked fund; and clear
assignment of roles across relevant government entities. Cost projections indicate ABC.
Sustaining RBF beyond project life cycles requires evidence of impact, careful review of
implementation experience, and strong leadership to translate operating modalities to
government systems and practices. Public nance and civil service rules can force adaptations
of common RBF design features, such as the direct payment of bonuses to health workers.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
2
1, Robert Akparibo1, Laura Gray1, Richmond Aryeetey2 and Richard Cooper1, (1)
University of Shefeld, Shefeld, United Kingdom, (2)University of Ghana, Accra, Ghana
Despite policy interest in enhancing cancer service coverage through the Ghanaian National
Health Insurance Scheme, multiple social-cultural, economic and health system factors
inuence how patients rst contact, negotiate and accept suitable cancer care in Ghana,
hindering efforts to alleviate inequality. Understanding such factors and how they relate is
important to enable policy-makers to plan future services and understand associated cost-
efciency and equity impacts. However, these factors have not been mapped and analysis of
the most appropriate methods to explore them from a systems perspective has not yet been
undertaken.
To systematically review and critique literature to understand factors inuencing cancer
treatment service access in Ghana and the most suitable methods to research this.
A critical interpretive synthesis approach was used to incorporate multiple types of evidence.
Multi-level literature searches were conducted using Medline via Ovid, Web of Science,
CINAHL and African Index Medicus. Supplementary searches were conducted in six Ghanaian
and African Journals, and by checking references and following up citations. Screening
was conducted using the PerSPECTiF framework by the lead author and checked by a
review author. The socioecological model (intrapersonal, interpersonal, community, health
system, and policy) guided data extraction and synthesis to identify themes. were
mapped against the candidacy framework (reframing access to encompass negotiation
and acceptance). A critique of the assumptions, methodology and interpretation within the
evidence body was conducted to identify themes in research gaps.
From 312 initial citations identied, 203 abstracts and 78 full texts were screened after duplicate
removal. A further 16 abstracts were screened following citation and reference searching.
Twenty-ve articles were selected for inclusion.
Multiple dynamic and interacting factors were identied at each socioecological model level
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
and across the candidacy framework stages, which inuenced how patients access cancer
treatment services. Preliminary analysis revealed barriers included costs and misconceptions
relating to traditional spiritual views, inuenced by community networks. Literature
highlighted acceptance of services was complex, involving delays, breaks and loss to follow up,
and not fully reected in the current candidacy framework.
Limitations were identied in how access to cancer care was dened and explored. Most
quantitative studies used retrospective hospital records without individual psychosocial
information and qualitative studies sampled predominantly from tertiary clinics, under-
representing the most neglected populations.
Future research should focus on populations under-represented in tertiary clinics to
understand the barriers and inequities they face that policy innovations could seek to tackle.
, Kyambogo University, Kyambogo, Uganda
In today’s fast paced and competitive market, optimal allocation of budgeted expenditure
poses a critical concern among healthcare practitioners worldwide. As the demand on health
systems increase due to HIV patients, constraints on healthcare budgets are signicant due
to budgetary constraints in less developed countries. In low income countries, the costs of
seeking and obtaining care is considerable due to prevalence of charges for services and
distances people often have to travel to obtain healthcare.
In this study, a goal programming model was developed to allocate budgetary expenditure for
treating HIV patients at Mulago hospital in Uganda
The relevant cost components under consideration included drugs, materials, labor and
miscellaneous costs. The weighted goal programming model proposed initially denes
the objective function. The model seeks to minimize the deviation variables from actual
expenditure; subject to the goal values of budgeted expenditure for HIV treatment. The sum
of weighted deviations is minimized so that actual expenditure on drugs, materials, labor
and miscellaneous costs meets the budgeted expenditure. The simplex method for linear
programming is used to solve the goal programming model; and a numerical example is
presented to determine the overachievement or underachievement of budgetary priorities.
The results obtained from the model developed aim to provide empirical evidence and
insights to decision makers and policy analysts for budgetary planning in healthcare facilities.
Certain goals on drugs, materials, labor and miscellaneous costs can be fully, partially or not
achieved at all. This however depends upon the priority levels and cost targets set in line with
budgeted expenditure on resource inputs for HIV treatment. Results also indicate that the
priority-based weighted goal programming solution for budgetary HIV treatment is more
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
sensitive to the highest priority objective function.
The numerical example presented provides useful insights for effective nancial planning
towards HIV treatment. Based on the results, budgetary planning for HIV treatment is crucial
for sustainable healthcare service provision in order to allow hospitals to identify satisfactory
allocation of expenditure; based on the priority levels or goals set for targeted expenditure
on HIV treatment. The results associated with the model indicate that a given priority in
one budgetary expenditure may not necessarily cause a signicant sacrice in another
expenditure. The model can however be effective; where relevant cost categories can be
prioritized if necessary.
1, Paul Revill2, Stefano Malvolti3, Melissa Malhame3, Mark Sculpher4 and Paul
M. Kaye5, (1)Center for Health Economics, University of York, York, United Kingdom, (2)Centre
for Health Economics, University of York, York, United Kingdom, (3)MMGH Consulting, Zurich,
Switzerland, (4)Centre for Health Economics, University of York, United Kingdom, (5)York
Biomedical Research Institute, Hull York Medical School, University of York, United Kingdom
A pressing need exists to develop new health products, such as vaccines for neglected
diseases such as leishmaniasis, that have potential to offer population health gains. Product
development is dependent on value as seen my two key players – product developers/
manufacturers, who need to have condence in the global demand in order to commit to
research and production; and governments (or other international funders) who need to signal
demand based on the potential public health benets and affordability.
A detailed global epidemiological analysis is rarely available for new products before they
enter market, due to lack of resources as well as typically insufcient global data necessary
for such analyses. This study seeks to bridge this information gap by providing a generalisable
approach to estimating the commercial and public health value of a vaccine for leishmaniasis
in development relying primarily on publicly available Global Burden of Disease (GBD) data.
Based upon estimates of incidence in selected countries, potential for individual health
improvement (measured using DALYs) and estimates of countries’ abilities to pay for health-
improving intervention, a global demand curve is constructed to demonstrate market size and
spur investment in product development. This simplied approach is easily replicable and can
be used to guide discussions and investments other new health products.
The maximum ability-to-pay of a leishmaniasis vaccine (per course, including delivery costs),
given the current estimates of incidence and population at risk, is higher than $5 for nearly half
of the 24 countries considered, with a median value-based maximum price of $4.4-$5.3, and
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
total demand of over 560 million courses.
The results indicate the commercial viability and potential for cost-effective population health
improvement. They are being used to support continued development of the most promising
vaccine candidate. Further development of this generic modeling approach is ongoing.
Principle organizer: Justice Nonvignon, Head of Health Economics Unit Africa CDC
Co-organizers: Tom Drake, Centre for Global Development, Anna Vassall, London School of
Hygiene and Tropical Medicine
Covid vaccination remains a critical issue for African countries and tough decisions remain
for African governments on how to obtain sufcient vaccine supply without jeopardising
essential services and how to effectively and equitable deliver the supply available. In this
session we present outputs from a programme of work on Health Technology Assessment
(HTA) on Covid-19 vaccines, coordinated by the Health Economics Unit in Africa CDC and
the International Decision Support Initiative. The presentations will include applied HTA’s in
Nigeria, Ethiopia and Kenya, including assessments of the comparative cost-effectiveness of
different Covid vaccines. There will be a presentation of optimal delivery strategies in African
countries, assessed using advanced economic and epidemiological modelling. Finally, there
will be an introduction to a toolkit for African countries seeking to collect evidence to inform
Covid-19 vaccine procurement decision making. The toolkit was published by the Center for
Global Development in November 2021 and can be foundhere.Technical presentations will
be followed by a panel discussion. The nal list of panellists is to be determined but currently
agreed participants include Prof Justice Nonvignon (Africa CDC) and Dr Raymond Hutubessey
(WHO).
Summary of presentations:
A. Health Technology Assessment of Covid-19 Vaccines in Nigeria (Professor
Benjamin Uzochukwu, University of Nigeria)
B. Health Technology Assessment of Covid-19 Vaccines in Ethiopia (Firmaye Bogale,
Ethiopian Institute of Public Health)
C. Economic and Epidemiological Modelling of Covid Vaccine Delivery Strategies in
African Countries (Dr Yang Liu, London School of Hygiene and Tropical Medicine)
D. Collecting Evidence to Inform COVID-19 Vaccine Procurement Decisions: A Toolkit
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for African Countries (Dr Tom Drake, Center for Global Development)
E. Health Technology Assessment of Covid-19 Vaccines in Kenya (Stacey Orangi,
KEMRI)
Presenter: Benjamin S.C. Uzochukwu, University of Nigeria
The COVID-19 pandemic has had varying impact at many levels in Nigeria. As part of its
control,three highly efcacious COVID-19 vaccines (Moderna, Oxford-Astra Zeneca, and
Johnson and Johnson) have been rolled out in Nigeria. However, access to these vaccines
have been limited and deployment slow. There is also limited evidence in Nigeria on the
comparative clinical and cost-effectiveness of alternative COVID-19 interventions including
vaccination against COVID-19 in the Nigerian context.Therefore, there is an urgent need to
support key national and regional policy priorities on COVID-19 by presenting evidence-based
approaches in Health Technology Assessment (HTA) to conceptualize and evaluate COVID-19
vaccine strategies in Nigeria.
The aim of this HTA is to provide decision makers with evidence on the optimal strategy for
COVID-19 vaccination to support policy priorities arising from a Nigerian context. The HTA
focused on four vaccines: Moderna, Pzer-BioNTech, Oxford-Astra Zeneca, and Johnson and
Johnson. And thede novocost-effectiveness analysis (CEA) focused on the following questions:
• Which Covid-19 vaccines should be bought and how much? What is the maximum price
to pay?
• Which is the best way to deliver each/ all vaccines?
• What is the cost and cost-effectiveness of vaccinating those aged 18-49 years old?
The cost-effectiveness analysis assumes a 12-month implementation period for all scenarios
and delivery strategies (campaign, targeted campaign, health facility).
Key
The results showed that the COVID-19 vaccines evaluated in this HTA can be highly effective
and cost-effective, although an important determinant of the latter is the price per dose and
the age groups prioritised for vaccination. Taking a health system perspective only, thede
novo CEA presented would suggest that the vaccines produced by AstraZeneca and Johnson & Johnson may
represent optimal choices from the Nigerian perspective. If funds are being drawn from current health budgets
vaccines priced under 10 USD/ dose and preferable 6 USD/dose or less compare favourably with other technologies
that could be provided within the health budget. Furthermore, it is more cost eective to prioritise age group
50+ cohort during phase 2 of the roll-out. However, different types of delivery strategies make little
difference to the results.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Costs for each of the delivery strategies (campaign, targeted campaign, health facility) differ
only slightly and do not appear to impact on relative cost-effectiveness. However, costs are not
adjusted for different scale up scenarios and there may be unmodelled constraints affecting
implementation.
Presenter: Firmaye Bogale, Ethiopian Institute of Public Health
Like all countries, Ethiopia has suffered large economic and health consequences form
COVID-19 and is hoping to use vaccinations to alleviate most of its effects. However, questions
around which vaccines to purchase and who to vaccinate still don’t have a clear answer.
Given the uncertainties around COVID-19, there is a need for a health technology assessment
to make informed decisions on COVID-19 vaccine. This should inform the national vaccine
strategy and ensure they get the best value for money out of their campaign.
Accordingly, this project aims to respond to the three policy questions below:
1. Which COVID-19 vaccines should be bought, and how much?
2. What is the best way to deliver the vaccines—xed posts, vaccination campaigns, or
outreach posts?
3. What is the cost and cost-effectiveness of vaccinating different target groups?
This was modelled for four vaccines, Pzer-BioNTech, Oxford-Astra Zeneca, Johnson and
Johnson, and Sinopharm. The cost-effectiveness analysis assumes a 24-or 36-month
implementation period for all scenarios and delivery strategies.
Additionally, interpretation of the evidence was contextualized taking into consideration
equity/access, vaccine hesitancy, budget impact, implementation issues, and wider benets
and harms.
Key
Taking a health system perspective, this research found that some vaccines were highly
cost effective in Ethiopia. In some scenarios the impact that the vaccines had on reducing
hospitalisation and other COVID-19 related treatment costs was cost saving for the entire
health system.
This research found that the cost of the vaccines was a much bigger driver than efcacy in
determining which vaccines offered the best value for money in Ethiopia. This suggests that
the vaccines made by Johnson and Johnson or AstraZeneca might provide the optimal choice.
However, if other suppliers were to reduce the price they are willing to sell their vaccines at in
Ethiopia that could lead them to become comparable.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
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Presenter: Dr Yang Liu, London School of Hygiene and Tropical Medicine
The enormous disease burden resulting from the COVID-19 pandemic has driven
unprecedented efforts to develop and distribute COVID-19 vaccines. By the end of 2021, nearly
30 vaccines have been approved in at least one country. As vaccine demand continues to rise
(as a result of the emergence of Variants of Concerns (VoCs) or the potential waning immunity),
vaccine production and supply have struggled to catch up. Making the most of limited
numbers of vaccines remains a policy question relevant for public health decision-makers
around the world.
Through our project, we evaluated the health and economic outcomes associated with
different vaccine strategies in a wide range of population and outbreak contexts among
African countries. Existing evidence is predominantly based on high-income and resource-
abundant settings with good access to and ability to distribute large volumes of vaccines.
However, one size may not t all. The settings that have already been explored often share
key features (e.g. population age structure, vaccine supply conditions) that affect COVID-19
transmission dynamics but are not applicable elsewhere in
the world. Here, we have addressed this issue by parameterising such features with local
contexts. We have also examined the unique challenge of rolling out vaccines as VoCs (e.g.
Omicron) spread.
On the country level, we used population sizes, age structures, and synthetic contact matrices
to construct the baseline population dynamics, and then Google Mobility and the Oxford
COVID-19 policy Stringency Index to approximate the deviation in human behaviours from
the aforementioned baseline. We t an age-specic transmission dynamics model to observe
COVID-19 mortality to estimate the sizes of existing outbreaks before (and during) vaccine
roll-out. We considered ve types of vaccine effects (i.e. preventing infections, disease, severe
disease, mortality and onward transmission) and explored a range of potentially feasible dosing
dynamics.
We projected the health outcomes associated with different vaccine dosing dynamics
strategies and presented the total costs, disability-adjusted life-years (DALY) and quality-
adjusted life-years (QALY) losses averted both on the national and the regional levels.
Presenter: Dr. Tom Drake, Center for Global Development
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Vaccines are key to controlling COVID-19 in Africa, but available supplies across the continent
remain extremely low—in most countries, doses are not even enough to vaccinate 1 in 10
people. Global, regional, and national institutions have created mechanisms to procure
vaccines and deploy them to their populations. Those organizations face important decisions,
with the potential to protect societies and economies from further COVID-19 shocks, but also
present a risk to essential services if the cost of COVID-19 vaccines depletes scarce health
budgets.
We have developed a toolkit which aims to support technical staff and decision-makers in
countries that are interested in using Health Technology Assessment (HTA) to inform the
procurement of COVID-19 vaccines. After introducing the HTA process, it focuses on evidence
collection, outlining the types of information useful to make informed decisions, and options
for frameworks to harness data. The toolkit also points to relevant existing evidence, resources
and key considerations from experiences garnered since the beginning of the pandemic.
The presentation will briey outline the purpose and structure of the toolkit, highlighting what
is can be used for and what it cannot. The toolkit is availablehere.
Presenter: Stacey Orangi, KEMRI-Wellcome Trust
The Kenyan Government has prioritized vaccination as a vital public-health measure to contain
the COVID-19 disease within the country. However, resource constraints necessitate a cost-
effective analysis of the implementation of various vaccination strategies within the country.
We used an age-structured SEIRS SARS-CoV-2 transmission model with vaccination to
project the epidemiological outcomes of implementing various vaccination strategies within
the country. Subsequently, the cost effectiveness of the various vaccination strategies was
estimated. We compared 3 vaccination scenarios against a no vaccination case: 30% (minimal),
50% (median) and 70% (optimistic) coverage of the adult population by June 2022 initially
prioritizing high-risk age groups. These were evaluated under two contexts: 1) without an
immune escape variant and with an immune escape variant, and 2) a rapid vaccination roll-
out and non-rapid vaccination roll-out. The incremental cost-effectiveness ratio (ICER) of each
option compared to the no vaccination case was estimated by calculating the incremental
cost of a strategy per Disability-Adjusted Life Years (DALYs) averted. A strategy is deemed cost-
effective if the incremental cost per DALY averted is less than 50% of the Kenyan GDP per
capita (USD 919.105).
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In the absence of a new variant in Kenya, minimal coverage (30%) with rapid roll-out achieves
the lowest cost per DALY averted because such a policy rapidly vaccinates all the most at-risk
population. In the event of a fth wave due to an immune escape variant ICERs are reduced
since there are more cases to be prevented for the same level of coverage. Investments in the
COVID-19 vaccine programme to increase coverage will result in fewer hospitalizations and
deaths, but the benets come at a high nancial burden. The current situation in Kenya after
four waves of COVID-19 is that over 80% of the population are believed to have experienced
natural infection and high-level population immunity. The present study shows that the role of
vaccination in such a setting favors rapid roll-out to those most at risk of severe disease, that is,
older age groups and those with co-morbidities.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Anooj Pattnaik, ThinkWell, Edwine Barasa, Health Economics Research Unit, KEMRI-
Wellcome Trust Research Programme, Nairobi, Kenya, Marie-Jeanne Offosse, ThinkWell,
Ouagadougou, Burkina Faso and Orokia Sory, Recherche pour la Santé et le Développement
(RESADE), Ouagadougou, Burkina Faso, Stacey Orangi, Institute of Healthcare Management,
Strathmore University, Nairobi, Kenya, Angela Kairu, Kemri-Wellcome Trust, Nairobi, Kenya
and Ileana Vilcu, ThinkWell, Geneva, Switzerland, Freddie Sengooba, Department of Health
Policy, Planning & Management, Makerere University School of Public Health, Uganda
COVID-19 has resulted in substantial health, social, and economic impacts globally. A key
dynamic of the pandemic is its bi-directional interaction with the health system. On the
one-hand, the capacity of health system functions affects the effectiveness of the country’s
response to the pandemic, and on the other hand, the nature, scale, health and non-health
impacts of the pandemic, and country response strategies affect health system functions
in ways that inuence the resilience of health systems. This is especially the case in low-and
middle-income countries (LMICs) that have fragile health systems. Resilience reduces the
vulnerability of health systems to crisis and ensures they adapt to support the continued
delivery of good quality services and address emerging health needs appropriately.
Understanding this interaction between the pandemic and health system functions is
important in providing evidence on how to a) strengthen health systems to better respond
to the pandemic and b) shape government response to the pandemic in ways that minimize
unintended and harmful health and social economic impacts. In other words, such evidence is
useful in informing ways to strengthen the resilience of health systems to COVID-19 and other
future pandemics.
This cross-country study conducted in three LMICs African countries (Burkina Faso, Kenya, and
Uganda) focuses on the health nancing function of the health system and examines a) how
the COVID-19 pandemic and government response to it has impacted their health nancing
systems, and b) how existing and adapted health nancing arrangements have affected the
capacity of these countries to respond to the pandemic.
Using Burkina Faso, Kenya, and Uganda as country case studies, this session will explore how
the COVID-19 pandemic and LMICs health nancing systems have inuenced health system
resilience. KEMRI-Wellcome Trust will open the session of with a presentation of the cross-
country study and its key ndings. Next, speakers from ThinkWell and Recherche pour la
Santé et le Développement (RESADE) in Burkina Faso, KEMRI-Wellcome Trust in Kenya, and
Makerere University School of Public Health in Uganda will share insights from their countries,
elaborating on how the purchasing and public nancial management arrangements have
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
been adapted to respond to COVID-19 and how these inuenced the pandemic response in
their country. ThinkWell will moderate a “question and answer” session, channeling audience
questions to the speakers.
Edwine Barasa, Health Economics Research Unit, KEMRI-Wellcome Trust Research
Programme, Nairobi, Kenya
The COVID-19 pandemic has resulted in substantial health and social-economic impacts
globally. A key dynamic of the pandemic is its bi-directional interaction with the health system.
On one end, the capacity of health system functions affects the effectiveness of the country’s
response to the pandemic; and on the other, the pandemics’ impact, and country response
strategies test the resilience of health systems and their functions. One such function is health
nancing, which plays a critical role in the pandemic response and maintaining the delivery of
core health services. We carried out a study in Burkina Faso, Kenya, and Uganda that focused
on the interaction between the pandemic and the health nancing function of their health
systems.
We aimed to examine a) how the COVID-19 pandemic and government response to it has
impacted their health nancing systems, and b) how existing and adapted health nancing
arrangements have affected the capacity of these countries to respond to the pandemic.
We used a comparative case study approach that employed quantitative and qualitative
methods. Quantitative data (e.g., budget and expenditure data) was extracted from document
reviews and descriptively analyzed in MS Excel. For the qualitative, we purposively sampled
national and regional health sector policy makers and managers, health facility level managers
and frontline staff (at referral and primary care levels) from each country. We collected data
using a combination of semi-structured in-depth interviews and document and administrative
record reviews. Triangulation of qualitative and quantitative data was used to enhance the
study rigor. A thematic approach was used for the analysis.
This cross-country study highlighted (1) how governments in Burkina Faso, Kenya, and Uganda
mobilized resources to respond to the pandemic, (2) what COVID-19 services were purchased,
and the purchasing arrangements used, (3) the evolution of purchasing rules and practices
during the pandemic and the opportunities seized and/or missed, and (4) lessons on public
nancial management adaptations especially during emergencies such as the COVID-19
pandemic.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Understanding the interaction between the pandemic and the different aspects of the health
nancing function is important to provide evidence on how to a) strengthen the health
nancing system to better respond to crises and b) shape government response to pandemics
in ways that minimize unintended and harmful health and social economic impacts. This
cross-country analysis enhances the transferability of these ndings to similar contexts in sub-
Saharan African countries.
Marie-Jeanne Offosse, ThinkWell, Ouagadougou, Burkina Faso and Orokia Sory, Recherche
pour la Santé et le Développement (RESADE), Ouagadougou, Burkina Faso.
The rst COVID-19 cases in Burkina Faso were conrmed on March 9, 2020. In early May, the
government set up the National Response Management Committee. Five-line ministries,
including the Ministry of Health (MoH), were involved in the implementation the COVID
response plan. To respond to the pandemic whilst continue to provide other essential health
services, the Government of Burkina Faso adopted swift health nancing reforms, specically
on public nance management (PFM) for revenue mobilization.
This study aims to assess key changes in health nancing arrangements in relation to Burkina
Faso’s response to the COVID-19 pandemic.
The study is part of a cross-country assessment with a standard questionnaire adjusted to
focus on relevant stakeholders in Burkina Faso. A detailed desk review of the literature on
PFM systems and practices at different levels of government in Burkina Faso was undertaken,
followed by key informant interviews on changes in revenue mobilization arrangements and
practices at the national level. A thematic approach was used for the analysis.
The 2020 MoH budget was revised to allocate 78 million USD to fund the pandemic response,
including incentives to motivate health workers. The new budget line was co-funded by the
government by repurposing some funds allocated to the MoH and other line ministries, and by
donors through direct budget support. The budget amendment resulted in an additional 43
million USD to the initial 335 million USD in the 2020 MoH budget.
For further resource mobilization, a treasury account (MoH COVID-19 account) was created
for direct deposit and bank transfers. MoH organized fund-raising events to collect cash and
checks from private companies and individuals. These funds were then deposited in this
treasury account.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
To facilitate the implementation of the COVID-19 response plan, the government streamlined
MoH procurement procedures. Single source (direct agreement) was allowed and resulted in
shortening procurement processes for COVID-19 treatment equipment.
Though the COVID-19 pandemic has disturbed services delivery in Burkina Faso, especially
preventive services, it has paved the way for reforms in PFM arrangements in the health
sector. Reallocation of government general budget to respond to a health crisis, innovative
approaches for public and private funds mobilization, as well as streamlining procurement
procedures are reforms that can be employed in future health crises.
Stacey Orangi, Institute of Healthcare Management, Strathmore University, Nairobi, Kenya,
Angela Kairu, Kemri-Wellcome Trust, Nairobi, Kenya and Ileana Vilcu, ThinkWell, Geneva,
Switzerland
By late October 2021, there have been over 252,000 conrmed COVID-19 cases and more
than 5,000 reported deaths in Kenya. In the face of the pandemic, the Kenyan health system
has had to continue to perform and deliver core services while ensuring there is capacity
to respond to the pandemic. Health nancing is a key health system function whose
performance impacts both of these objectives.
This study examined how the Government of Kenya adapted its purchasing and public
nancial management (PFM) arrangements to respond to COVID-19 and how these inuenced
the pandemic response in the country.
To better understand this, we conducted a qualitative and quantitative cross-sectional study at
the national level and in three purposely sampled counties in Kenya. We collected qualitative
data using in-depth interviews (n=55) and carried out document reviews to extract quantitative
budget data. Qualitative data was analysed using a thematic approach, while qualitative data
was analysed descriptively in MS Excel.
COVID-19 services offered in the counties include testing, isolation and case management,
as well as vaccination. Across the three counties, these services are purchased by the county
health department and national ministry of health and provided largely through public
healthcare facilities. The COVID-19 services are paid for using program-based budgets.
Although the National Hospital Insurance Fund (NHIF) has not formally incorporated COVID-19
services into its benet package, there are efforts to include COVID-19 case management in
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
some of its schemes and reimburse through existing payment methods (capitation, fee for
services, case-based payments, and daily per diems).
Existing PFM systems across the three counties remained unchanged, however, the budgeting
process was exible to include COVID-19 related activities. Counties (two of the three) where
health facilities lacked operational and nancial autonomy were less able to respond to the
urgent needs of the facilities resulting in delays in procurement.
Our ndings show that there is need to increase access of COVID-19 services by including it in
the NHIF benet package and including more private and faith-based facilities to offer these
services. Further, although the current public nance management systems have been exible
in responding to the pandemic, adaptations such as ensuring facility nancial autonomy are
key to making the health nancing system more resilient to pandemics.
Freddie Sengooba, Department of Health Policy, Planning & Management, Makerere
University School of Public Health, Uganda
Like many countries, Uganda’s decentralized system transmits the responsibility for health
service delivery to local governments. The capacity of these local governments to withstand
pandemics and sustain health service delivery is key. At the beginning of the COVID-19
pandemic, the Government of Uganda (GoU) mobilised funds to nance national and local
government responses. Effective resource mobilization, allocation, and use is key to health
system resilience during health emergencies, and much can be learned from the interactions
between Uganda’s COVID-19 pandemic response and its public nancial management (PFM)
systems and what adaptions were undertaken in this crisis.
This study assesses Uganda’s COVID-19 funding mechanisms, documenting how its health
purchasing arrangements were adapted and comparing the de jure versus de facto autonomy
levels for scal and operational decision-making by districts and health facilities. The study
describes how COVID-19 nancing evolved during the pandemic, with attention to how funds
were mobilized and used to pay providers, and how they were accounted for.
A cross-sectional study was conducted across 43 health facilities in 8 districts. In-depth
interviews at the national level helped to clarify purchasing decisions for COVID-19. Descriptive
and comparative statistics were calculated to show implementation progress, and qualitative
data collected through open-ended questions were analyzed using conventional content
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analysis (CCA) to determine the pattern of nancial ows and spending priorities for COVID-19
interventions. Supplementary information was extracted from relevant laws, policies, and
guidelines.
This study determined the scal and operational autonomy sub-national governments and
facilities have within the public health system. Findings highlighted (1) how GoU mobilized
resources to respond to the pandemic, (2) what COVID-19 services were purchased, and
the purchasing arrangements used, (3) the evolution of rules and practices for strategically
purchasing during the pandemic and what opportunities were seized and/or missed, and (4)
lessons on adaptations about vital adjustments in PFM especially during emergencies like
COVID-19.
The COVID-19 pandemic prompted rapid efforts by the GoU to mobilize funds and allocations
to service providers. New approaches to purchasing emerged, prompting adjustments
to PFM practices. Uganda’s experience sheds light on whether health emergencies can
increase government willingness to grant greater scal and operational autonomy to local
governments and frontline facilities.
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Mr. Gavin Surgey, Radboud University Medical Center, Nijmegen, Netherlands, Brian
Asare, Ministry of Health, Accra, Ghana, Tommy Wilkinson, World Bank, Washington, DC,
Warren Mukelabai Simangolwa, HEARD, Health Economics Aids Research Division, UKZN,
Lusaka, Zambia.
The use of data and evidence for decision making in HTA: Adopting an evidence deliberative
process as a mechanism for strengthening decision making in Health Technology Assessment.
With limited resources, tough choices must be made about what gets covered.
There has been increasing use of Health Economics evidence to support decision making
however, it is being realized that decision making needs to rely on more than Cost-
Effectiveness (CEA) and that a countries’ value criteria needs to be incorporated such as
disease and intervention criteria; criteria related to characteristics of social groups and; those
related to protection against the nancial and social effects of ill health.[1]
There is a need for fair processes and procedures to capture multiple considerations and
navigate the tensions and tradeoffs. Given that people will disagree about which tradeoffs
ought to be made, a commitment to fair processes can help navigate these challenges. It is
within this context that an evidence-informed deliberative process can help navigate these
tradeoffs resulting in fairer and more legitimate decision making.
Different countries use and consider different evidence in their decision making. What
evidence do they consider and how? This session will reect on what and how different
countries consider different types of evidence for legitimate decision making.
The session will start with the moderator setting the scene with an overview of experiences
with priority setting and evidence that is used for decision making. There will be comment on
the role of value criteria and how this is derived and used in different country HTA processes.
After that the ve panellists will present their work relating to the use of evidence in HTA in the
different countries followed by a Q&A.
The objectives of this panel will be to share the experiences of using different criteria as
countries move toward the institutionalization of HTA for priority setting.
[1] Norheim, O.F., Baltussen, R., Johri, M. et al. Guidance on priority setting in health care (GPS-
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Health): the inclusion of equity criteria not captured by cost-effectiveness analysis. Cost Eff
Resour Alloc 12, 18 (2014). https://doi.org/10.1186/1478-7547-12-18
Brian Asare, Ministry of Health, Accra, Ghana
Ghana is committed to achieving Universal Health Coverage (UHC) and has been working
to encourage evidence-based decision making to ensure the National Health Insurance
Scheme (NHIS) works for Ghana’s 30 million citizens by establishing HTA. In order to achieve
Sustainable UHC, Ghana has recognized that this requires developing frameworks for priority
setting. On the path towards UHC, Ghana needed to make choices in the design of the HTA
frameworks and processes. It was agreed that an evidence-informed deliberative process
(EDP), adapted to the country-context based on lessons learnt from the use of evidence and
negotiation in the review of national standard treatment guidelines and essential medicines
list would be followed. Work was done with the with the Ghana HTA committee on the types of
criteria that could be used for decision making which included factors additional to clinical and
economic evidence such as ethical, legal, or social issues. Throughout the development of HTA,
work has been done with stakeholders in the country to increase the understanding of choices
in processes and the theoretical framework of EDPs. This work will present the process that
Ghana followed in designing its framework for HTA, from the inception of its HTA structures,
to the drafting of each step in the HTA process guidelines by the country HTA structures,
to the implementation of initial HTA-related projects to inform policy making. We nd that
incorporating ideals from existing processes and involving decision-makers in the design
plus may contribute to success of HTA. Also, that incorporating evidence beyond exclusively
focusing on cost-effectiveness will result in fairer priority setting processes.
Mr. Gavin Surgey, Radboud University Medical Center, Nijmegen, Netherlands
HTA has increasing recognition of its role as an important component to achieving UHC
through more efcient allocation of resources. There is no formalized priority-setting
mechanism in Tanzania, and current decision-making processes do not incorporate health
economic analysis (efciency, effectiveness, value and behaviour). Decisions are taken by
the leadership at the national level and are made in a bureaucratic fashion, with little or no
evidence to underpin them. Very hot debates among the researchers, politicians and in the
communities called for more systematic discussions at the ministry level. As Tanzania moves
toward universal coverage reforms, are focused on improving efciency. Health services are
not well dened and there is desperate need for HTA to help dene priority services as well
as a process for doing so, in order to ensure best value for money and broader stakeholder
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buy in of coverage decisions. This work aims to present, as a case study, the successful
establishment of the Tanzania HTA committee in 2017/18. It aims to answer the question: How
does one introduce HTA such that HTA becomes an integrated part of routine decision-making
for planning and operational policy within the health care system when there are a lack of
capacity and data. The presentation will highlight how decisions are made and how evidence
is used in an evidence scarce environment. We will show how the HTA process has been
simplied, but by using the available evidence we can improve the decision making process
leading to a more efcient health care system.
Tommy Wilkinson, World Bank, Washington, DC,
The Essential Drugs Programme (EDP) in South Africa aims to ensure that affordable, good
quality essential medicines are available at all times, in adequate amounts, in appropriate
dosage forms, to all citizens. New health technologies introduce additional costs to the health
system, meaning their availability introduces challenges for priority setting, resource allocation,
and patient care choices. Choices need to be made between alternative interventions for a
given disease and treating or preventing it. In order to make these complex choices, the EDP
aims to utilise the best available evidence using an approach that is systematic, unbiased, and
transparent.
An HTA process was developed for the EDP which focuses on the methods for the production
and use of evidence for medicines. This is nested in the context of South Africa’s developing
health technology assessment (HTA) system. This system of HTA in South Africa goes beyond a
technical exercise and incorporates a series of social and scientic value judgments to inform
an accountable approach to determining what health technologies are funded in the public
health system. This presentation outlines the HTA methods used within the existing decision-
making in the current South African context and in future structures under National Health
Insurance.
Warren Mukelabai Simangolwa, HEARD, Health Economics Aids Research Division, UKZN,
Lusaka, Zambia
The Ministry of Health in Zambia has recently initiated a process to revise the 2012 National
Health Care Package (NHCP). This is a part of the broader health allocative efciency process
to improve value for money for its health spending. To achieve this, a roadmap dening a
stepwise process contextualised from the international decision support initiatives ten steps
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
what’s in and what’s out has been adopted for implementation. Applied economic evaluation,
measuring costs of health interventions, budget impact analysis, decision analytic modelling
and measuring health utilities and preferences are key health economics concepts that are
relevant to this process.
This article reviews processes that Zambia is undertaking to improve in-country
expertise in health economics so as to revise its benets package. In particular, we explore
two critical stages of it stepwise revision process and ascertain what capacity development
initiatives are being undertaken for the multi-stakeholder group appointed by Government to
lead this process. The multi-stakeholder group is an inclusive forum for cooperating partners,
academia, civil society groups, local and international NGOs, the private sector, regulatory
institutions, other government line ministries, patient groups, and public representatives. Their
roles are to generate evidence to inform decision making on benet package processes and
steer consensus on the revision. The stages reviewed are the evidence collection and synthesis
and the appraisal stages, corresponding to steps 4 and 5 on the ten stepwise process. The
outcomes to these processes will include synthesis and appraisal of evidence on intervention
costing, scal space, budget impact, CEA , equity and FRP evidence synthesis.
.
The Government of Zambia has initiated a monthly 60-90 minutes webinar for the multi-
stakeholder group to strengthen their Health economics capacity for the revision process.
These webinars host experts drawn from the iDSI network with expertise in health economics.
The Government has further been collaborating with the International Decision Support
Initiative, the World Bank, UNICEF and WHO to support health economics capacity. To
adequately and systematically achieve this, the Government is undertaking a capacity
assessment for the multistakeholder group to review specic capacity development needs for
stakeholders so as to target the health economic developments imitative better.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, USAID State2State Project of Development Alternative Incorporated (DAI)-
Nigeria, Uyo- Akwa Ibom State, Nigeria, Dr. Adenekan Abayomi, USAID Health Policy Plus
(HP+) Project of Palladium International Development Company – Osun state, Osun state,
Nigeria, Dr. Janet Ekpenyong, Primary HealthCare Development Agency –Cross River state,
Calabar-Cross River state, Nigeria, Andrew Carlson, USAID Health Policy Plus (HP+) Project of
Palladium International Development Company – USA and Dr. Frances Ilika, USAID Health
Policy Plus (HP+) Project of Palladium International Development Company – Abuja, Abuja,
Nigeria
Despite a plurality of funding mechanisms for health in Nigeria, gross under-funding
compared to projected need, inefciency and waste reduce the effective functioning of
the health system. To support the process of strategic reforms in healthcare nancing that
are currently ongoing and push more funds to the state level, there is a need for evidence
to inform policies that mobilize and then help utilize funding for health and support the
engagement of critical actors.
We conducted a public expenditure review (PER), scal space analysis (FSA), and assisted
state governments in developing Resource Mobilization Plans (RMPs) in two states: Abia
and Osun. The PER and FSA surveyed GDP growth, government revenue, budget and
expenditure indicators from ofcial sources over the ve-year period 2013–2017. Based on this,
we projected three scal space scenarios for health (baseline, moderate and optimistic), using
assumptions to account for uncertainty in prioritization of health and macro-scal conditions
in each state. The output from these analyses guided the development of RMPs that target
increasing health funding from four sources: (1) discretionary government health expenditure,
(2) earmarks, (3) external assistance and private sector, and (4) efciency gains. Results were
validated through stakeholder-led working sessions.
In both states, public funding for the health system fell below the 15% Abuja declaration target.
The proportion of government health expenditure to general government expenditure ranged
from an average of 5% in Abia to 7% in Osun for the period. Budgets prioritize personnel costs
(historical average of 69% of the health budget in both states) which crowds out other inputs
into health service delivery; while capital expenditure is poorly prioritized (average of 27%-28%).
Effectiveness of the capital spending is further reduced by poor execution (average of only 8%-
10% in both states). The nal Osun state RMP aims to mobilize 85 billion Naira over the period
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
2020–2024; building on underlying FSA scenarios and accompanying strategies. In Abia, the
RMP will yield 61 billion Naira within the same period.
In their RMPs, each state health sector committed to greatly improve both health prioritization
and budget performance through enhanced nancial data tracking and consequent
evidence-based advocacy efforts. In addition, RMP strategies targeting non-poor informal
sector enrolment into the state insurance schemes have great promise to mobilize additional
domestic resources. Together, this approach to linking health nancing output to strategic
planning should be considered in other Nigerian states aspiring for UHC.
1, August Kuwawenaruwa2, Mariam Ally3, Moritz Piatti3 and Gemini
Mtei4, (1)Ifakara Health Institute, Dar Es Salaam, Tanzania, (2)Ifakara Health Institute, Dar es
salaam, Tanzania, (3)The World Bank Tanzania, (4)Abt. Associates Inc., Public Sector Systems
Strengthening Plus (PS3+) Project, Dar es Salaam, Tanzania.
Achieving universal health coverage (UHC) goal by ensuring access to quality health service
without nancial hardship is a policy target in many countries. Thus, routine assessments
of nancial risk protection are required in order to track country progress towards realising
this universal coverage target. This study aimed to undertake a system wide assessment of
catastrophic health spending by using the recent national survey data in Tanzania.
We used cross-sectional data from the national Household Budget Survey 2017/2018 covering
9,463 households and 45,935 individuals cross all 26 regions of mainland Tanzania. This
data includes information on service utilisation, health care payments and consumption
expenditure. Two measures of nancial risk protection (i.e., catastrophic health expenditure
(CHE) and impoverishing effect of health care payments) were estimated. Prevalence of CHE
was estimated from the fraction of healthcare costs in relation to household consumption
expenditure. We used 10% threshold of total expenditure and 40% threshold of non-food
expenditure. Poverty headcount was estimated using the total household consumption
expenditure considering both with and without out-of-pocket expenditure for healthcare in
comparison with the national poverty-line.
About 2.6 percent of Tanzanian households suffered from nancial catastrophe because
they spend more than 10 percent of their total expenditure on health care. Also, 1 percent of
Tanzanian households suffered from nancial catastrophe because they spent more than
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
40 percent of their non-food expenditure on health care. Similarly, about 1 percent of the
population was impoverished as a result of out-of-pocket payments.
Tanzania should prioritize expanding pre-payment mechanisms such as health insurance
and progressive taxation to ensure nancial protection among vulnerable groups, specically
the poor, the elderly, those suffering from chronic illness. Further monitoring assessment are
needed especially in comparing nancial protection with the performance on service coverage
in the premise of achieving UHC.
, KEMRI-Wellcome Trust Research Programme, Centre for Geographic
Medicine Research (Coast, Kili, Kenya
High out-of-pocket (OOP) payments is one of the major factors hindering healthcare access
in Nigeria and other low- and middle-income countries. Available information indicates
a rising trend in OOP, putting many in risk of catastrophic health expenditure (CHE) and
impoverishment, especially among poor individuals. As most of the studies are limited only to
the amounts paid out-of-pocket this may lead to an underestimation of the phenomena for
the households that cannot afford these payments. There have been limited studies examining
the extent of inequality and determinants of CHE in sub-Saharan Africa. Using data from
Nigeria General Household Survey panel (GHSP) for 2018-2019, this study examines socio-
economic inequalities and determinants of CHE. The catastrophic effects of OOP payments
in this study were measured using Ataguba method, applying an initial threshold of 10% and
y=0.8, a parameter of aversion to inequality. Multiple corresponding analysis (MCA) was used
to generate the wealth index and concentration indices for assessing inequality were derived.
Logistic regression was used to analyse the association between CHE and socio-demographic
variables. The results indicate that 22.3% of the households incurred CHE at 10% threshold.
6% of outpatients and 4% of inpatients patients were impoverished or went below poverty
line due to OOP for health care. The computed concentration indices for both outpatients
and inpatients healthcare services were negative, indicating that CHE was concentrated
among the poor households. Furthermore, the results suggested that lack of health insurance
(OR=3.41, SE= 2.38, p<0.001), living in rural areas (OR=2.01, SE= 1.02, p<0.005) and low socio-
economic status (OR=1.48, SE= 0.57, p<0.005) were the variables associated with CHE. These
ndings have some policy implications for different stakeholders such as ministers for health,
health providers, insurance rms. Policies to enhance nancial risk protection, particularly
among the poor households and rural dwellers, are required to enhance equity and improve
healthcare access in Nigeria.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Hayden Bosworth1, John Bartlett2 and Chalres Muiruri1, (1)Duke University-
Department of Population Health Sciences, Durham, NC, (2)Duke Global Health Institute,
Durham, NC
Missed clinic appointments negatively impact clinic patient ow and health outcomes of
people living with HIV (PLHIV). PLHIV likelihood of missing clinic appointments is associated
with direct and indirect expenditures made while accessing HIV care. The objective of this
study was to examine the relationship between out-of-pocket (OOP) health expenditures and
the likelihood of missing appointments.
Totally 618 PLHIV older than 18 years attending two HIV care and treatment centres (CTC) in
Northern Tanzania were enrolled in the study. Clinic attendance and clinical characteristics
were abstracted from medical records. Information on OOP health expenditures,
demographics, and socio-economic factors were self-reported by the participants. We used
a hurdle model. The rst part of the hurdle model assessed the marginal effect of a one
Tanzanian Shillings (TZS) increase in OOP health expenditure on the probability of having
a missed appointment and the second part assessed the probability of having missed
appointments for those who had missed an appointment over the study period.
Among these 618 participants, 242 (39%) had at least one missed clinic appointment in the
past year. OOP expenditure was not signicantly associated with the number of missed clinic
appointments. The median amount of OOP paid was 5 100 TZS per visit, about 7% of the
median monthly income. Participants who were separated from their partners (adjusted odds
ratio [AOR] = 1.83, 95% condence interval [CI]:1.11‒8.03) and those aged above 50 years (AOR =
2.85, 95% CI: 1.01‒8.03) were signicantly associated with missing an appointment. For those
who had at least one missed appointment over the study period, the probability of missing a
clinic appointment was signicantly associated with seeking care in a public CTC (P = 0.49, 95%
CI: 0.88‒0.09) and aged between > 25‒35 years (P = 0.90, 95% CI: 0.11‒1.69).
Interventions focused on improving compliance to clinic appointments should target public
CTCs, PLHIV aged between > 25‒35 years, above 50 years of age and those who are separated
from their partners.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, John Bartlett2, Chalres Muiruri1 and Hayden Bosworth1, (1)Duke University-
Department of Population Health Sciences, Durham, NC, (2)Duke Global Health Institute,
Durham, NC
Catastrophic health expenditure (CHE) means that the health spending of an individual
exceeds their ability to pay. People living with HIV (PLHIV) incur CHE due to out-of-pocket
(OOP) expenditures made while accessing HIV care. CHE is associated with access and
adherence barriers that negatively impact health outcomes and risk transmission of HIV. We
assessed CHE and its associating factors among PLHIV in two care and treatment centers
(CTC) in North Tanzania.
We interviewed 618 PLHIV who were older than 18 years and assessed data on their
demographics, clinical characteristics, socio-economic status, monthly income, direct medical,
non-medical and indirect expenditures, and coping strategies while accessing HIV care. We
assessed CHE due to HIV as health expenditures exceeding 10% of total monthly income. A
multivariate logistic regression model was used to determine the predictors of catastrophic
health expenditures.
The mean total OOP health expenditure per HIV visit was TZS 7242 (standard deviation [SD]
2998). CHEs were experienced by almost half (45%) of the PLHIV attending the two CTCs.
Attending a private CTC (AOR 1.77; 95% CI 1.19-2.64) was associated with CHE while being in
the upper socio-economic status (AOR 0.42; 95% CI 0.23-0.79) and employment (AOR 0.19; 95%
CI 0.13-0.29) were protective against CHE. Borrowing money (AOR 3.69; 95% CI 2.46-5.52) and
reducing number of meals to pay for HIV care (AOR 1.57; 95% CI 1.05-2.32) were signicant CHE
coping strategies.
Implementing long-term economic protection schemes in HIV programs such as income
generating projects is key in ensuring PLHIV are protected against CHE. Future studies should
longitudinally assess how CHE and its coping strategies may impact health outcomes among
PLHIV.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, ECOLE DE SANTE PUBLIQUE DE KINSHASA, KINSHASA, Congo-
Kinshasa
In previous Ebola Virus Disease (EVD) outbreaks, the use of health services decreased, delaying
health-seeking behaviour and affecting the health of the population.
From May to July 2018, the Democratic Republic of Congo experienced an outbreak of
EVD. The Ministry of Health introduced a policy of free health care (PGS) in affected and
neighbouring health zones. We assessed the impact of this policy on health service utilisation.
The aim of this study was to determine the impact of MVE on health service utilisation and
health system performance in affected and unaffected areas where nancing strategies are
being piloted.
(1) Integrate routine health information into responses to Ebola in DRC and draw lessons for
future public health crises
(2) Identify drivers and barriers to health system performance that may be relevant to future
public health emergencies in DRC
We used a controlled interrupted time series analysis with a mixed effects model to estimate
changes in service utilisation rates during and after the free healthcare policy (FHP)
Overall, service utilisation increased compared to control health areas, including areas affected
by EVM. The total number of visits for pneumonia and diarrhoea initially more than doubled
compared to control areas (p<0.001), while assisted deliveries and antenatal rst aid increased
between 20% and 50% (p<0.01). DTP visits, fourth antenatal care visits and postnatal care visits
were not signicantly affected. During the GSP, visit rates followed a downward trend. Most of
the increases did not persist after the GSP ended.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The GSP was effective in rapidly increasing the use of some health services in both EVM-
affected and unaffected health areas, but this effect was not sustained. Such policies can
mitigate the negative impact of infectious disease outbreaks on population health.
Directorate of Coordination of the Expanded Programme on
Immunization, Abidjan, Côte d’Ivoire, Lepri Nicaise Aka, Directorate of Coordination of the
Expanded Programme on Immunization of Cote d’Ivoire, Alla Annita Emeline Hounsa, UFR of
pharmaceutical and biological sciences of the University Felix Houphouët Boigny, ABIDJAN,
Côte d’Ivoire, Stephane Sable, UFR of medical sciences of the University Felix Houphouet
Boigny and Kouadio Daniel Ekra, Directorate of coordination of the Expanded Programme on
Immunization, Côte d’Ivoire
AKA Desquith Angèle: +2250707812934, Directorate for Coordination of the Expanded
Programme on Immunization, Côte d’Ivoire, aka.desquith2017@gmail.com.
AKA Lepri Nicaise, HOUNSA Alla Annita, SABLE Stéphane, EKRA Kouadio Daniel
The health system’s response to Covid-19 must involve the population because their knowledge
of this pathology has a signicant effect on the pandemic. Côte d’Ivoire, which recorded its rst
case on 11 March 2020, has taken numerous actions to deal with this pandemic.
The objective of this study was to analyse the factors associated with people’s knowledge
about Covid-19.
The cross-sectional study with a mixed quantitative and qualitative approach took place
from 01 to 06 June 2020 in the Greater Abidjan health region constituting the epicentre of
the epidemic in Côte d’Ivoire. This survey concerned people from households aged 18 years
or older. Quantitative data were collected using a questionnaire. The data was entered using
CSpro software and analysed using R software for the quantitative survey. For the qualitative
part, the interviews were recorded and a content analysis was performed. Logistic regression
was used.
There were 165 respondents with a sex ratio of 0.57 M/F. The majority of respondents were
between 40 and 49 years of age with an average age of 39.5 ± 13.2 years. In terms of education,
14.5% of the respondents had no education and 27.3% had primary education. The average
knowledge scores were low. Indeed, the expected mean was 6, but the mean for our
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
population was 4.5 and the median was 4.8. Logistic regression showed that advanced age was
the only factor favouring poor knowledge. The qualitative survey revealed 3 representational
forms of the etiology of the disease, namely the biomedical type etiology where the disease
is due to a virus, the traditional type etiology where the populations link this pathology to a
divine sanction and a fatalistic approach.
Some local people in Abidjan doubt the existence of the disease and advocate the use of
traditional health care to recover health. The results of this study could help to develop
appropriate interventions.
Knowledge, Covid-19, Abidjan
Félix Houphouët University, Boigny Cocody, Abidjan, Côte d’Ivoire
The coronavirus (COVID-19) disease has spread rapidly from its Chinese epicentre to all parts
of the world, causing a global health and economic crisis. It has literally and guratively
translated the famous popular saying that “When China sneezes, the rest of the world catches
a cold”! By the end of October 2020, the number of COVID-19 cases in Africa had exceeded
1.5 million. The limited existing literature on the economics of pandemics focused on the
epidemics of Spanish u, acute respiratory syndrome in Asia and Ebola in Africa. Discussions
often focused on mortality, with little detail on the economic consequences of a pandemic. A
few studies have examined the macroeconomic impact of pandemics (Lee and McKibbin, 2003
and Edwards, 2005), but despite their important implications for policy-making, they have not
explicitly focused on Africa. More recently, the Economic Commission for Africa (2015) assessed
the macroeconomic impact of Ebola in affected West African countries.
Studies rarely look at the economic effects of the COVID-19 pandemic, which have often
been underestimated or downplayed, focusing more on mortality. COVID-19 has shown
how economic activities can be disrupted, how important it is to understand the economic
effects of pandemics, and what economic policies can be adopted to mitigate the health and
economic consequences. Our paper attempts to ll this gap by studying the macroeconomic
effects of the COVID-19 pandemic in Africa in general, and in Côte d’Ivoire in particular, using a
continent-wide aggregate macroeconometric model.
Our analysis shows that GDP growth in 2021 will be less than 6.2% compared to the baseline
situation without COVID-19. The scal decit will have widened and public debt will have
increased, but trade decits will have improved slightly.
We rst present a conceptual framework that examines the channels of transmission and the
ways in which the pandemic might affect economic activity in the short term. The Economic
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Commission for Africa’s macroeconomic model is briey discussed as a methodology for
studying the impact of the pandemic on African economies. This is followed by a presentation
of the macroeconomic effects of the pandemic. The nal section examines policies that could
mitigate the negative effects of the pandemic and accelerate the recovery process from the
crisis.
¹Siaka Lougue², Djamina Diallo² and Maxime Drabo², (1)
African Population Health Research Center, Dakar, Senegal, (2)Institut de Recherche en
Sciences de la Santé, Ouagadougou, Burkina Faso
The Covid-19 crisis started in Wuhan, China, and quickly spread to all continents. To address
the pandemic, a response plan with a budget was developed in Burkina Faso. Supporting the
response efforts required mobilising more resources from various actors. National initiatives
have made it possible to mobilise nancial and material resources. The aim of our study was
therefore to carry out a living map of the mobilisation of the various actors.
Our study consisted of a review of all contributions made in the framework of covid19 from
March 2020 to March 2021 in Burkina Faso. An exhaustive census of the contributions was
carried out through the use of key words for the search, which were “donation”, “covid-19”,
“coronavirus” and “Burkina Faso”. A monitoring system was set up from October 2020 on
Burkinabe websites. Variables concerning the date of the donation, the nature of the donation,
the name of the donor and beneciary, the nature of the donor and beneciary and the
amount of the donation were collected. The data was then compiled in a grid created in Excel
and analysed using SPSS version 20.
A total of 252 donations were recorded over the period. The majority of donations were in kind
(72%) and few in cash (13%). The nancial estimate amounts to more than 17 million euros. The
private sector is the largest contributor (30.5%) to the response to covid 19, while traditional
health sector funding partners accounted for 17%. The main contributors from the private
sector were mainly private companies (20%), mining companies (6.1%) and nancial companies
(4.5%). The main beneciaries were the public administration (45%) and the population (19%).
The challenge of responding to covid-19 has seen an unprecedented mobilisation in Burkina
Faso. The private sector is the main contributor. This could explain the effects of the crisis
on this sector. This dynamic of contributions must be understood as a lever for mobilising
domestic nancing in order to make it a basis for building a resilient nancing system in
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Burkina Faso.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Régine Attia1, Eric Kouamé2, Jerome Kouame1 and Kouame
Kof1, (1) Universite F H Boigny, Abidjan, Côte d’Ivoire, (2)AIRP
Many people do not have access to life-saving products, years after their discovery, particularly
in Africa. Importing medicines to cover more than 90% of needs limits the ability to negotiate
prices and adds to the burden on patients. Thus, unaffordable drug prices remain a barrier for
patients and health systems on the way to universal health coverage.
To determine the price structure and contribution of charges in the supply of medicines in
Côte d’Ivoire
To identify differences in drug pricing in WAEMU countries
A study was carried out in 2020 in four health care institutions, one health district, four private
pharmacies, four private wholesaler-distributors and the public purchasing centre, from the
patient to the importers, and also with the WAEMU National Pharmaceutical Regulatory
Authorities, on 26 pharmaceutical presentations. Data were collected for the original branded
product and the cheapest generic equivalent. Prices were compared on a purchasing power
parity basis using Actual individual consumption Purchasing Power Parities, with the United
States serving as the base with USD equivalent to 1.
Between the Wholesale Duty Free (WDF) or Delivery at Destination (DAD) price and the
nal price paid by the patient, twenty-two (22) charge items were identied overall. The
contribution of each charge to the patient price varied between the public and private sectors,
and between imported and locally produced products. The charges were superimposed for
brand-name and imported generic drugs. For local generics, the import charges were shifted
to the percentage of the HGV. Five values of Public Selling Price (PSP) to HGV ratios were found
mainly in UEMOA countries. There was no statistically signicant difference in price per unit of
dosage form at purchasing power parity on either the PVP or the PGHT.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
These results show the heavy burden of imports on the accessibility of medicines. They make it
possible to identify levers for action at different levels for a pricing policy.
, University of Education, Winneba, Winneba, Ghana
The economic impact from COVID-19 is being felt worldwide; yet the number of women
seeking safe abortion care is rising even in countries with abortion restrictions. Ghana has a
liberal abortion law aimed to enhance access to safe abortion services, yet there are limited
studies and no elaborate policies on pricing abortion services in the various health facilities.
Although abortion seekers in Ghana can access some level of care under the National Health
Insurance Scheme, the cost of induced abortion care is not usually covered in Ghana Health
Service facilities. For many women and girls, the deciding factor to access safe abortion care is
the nancial cost.
In this study the author examined determinants of pricing abortion services across various
licensed health facilities in Ghana.
This was a facility-based, mixed-method study design involving the collection of both
quantitative and qualitative data from primary and secondary sources within identied health
facilities owned by public, private and Non-Governmental Organizations (NGOs) that are
registered to provide safe abortion services in Ghana. Questionnaires and in-depth interview
guides were used for data collection between 2017 and 2020.
There is a signicant difference between the price of abortion services across private, public,
and NGO facilities in Ghana. There are also signicant differences in pricing abortion services
in private and NGO facilities (p=0.0201 < 0.05) as well as private and public facilities (p=0.0108 <
0.05), but there are no differences in the cost of abortion services in NGO and public facilities
(p=0.127> 0.05). It was generally observed that pricing abortion services in Ghana is unregulated
and there are no national policy guidelines to determine the pricing of induced abortion
services across the various service delivery channels.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The determinants of pricing abortion services are very subjective, facility-based, and subject
to the inputs for service delivery as well as the drive for sustainability. A national guideline on
pricing abortion care is required.
1, Obinna Onwujekwe2, Prince Agwu3, Aloysius Odii4, Dina
Balabanova5, Eleanor Hutchinson5, Martin McKee6 and Pallavi Roy7, (1)Health Policy Research
Group, Enugu, Nigeria, (2)University of Nigeria, Nsukka, Enugu Campus, Enugu, Nigeria, (3)
University of Nigeria, Nsukka, Nsukka, United Kingdom, (4)University of Nigeria, Nsukka,
Nsukka, Enugu, Nigeria, (5)The London School of Hygiene & Tropical Medicine, (6)London
School of Hygiene and Tropical Medicine, United Kingdom, (7)SOAS University of London,
United Kingdom
Pharmaceutical procurement take up a large proportion of health nancial resources,
and multiple actors are involved in the procurement process. The scale of funds, and the
multiplicity of actors involved in procurement creates opportunity for corruption. Poor
procurement practices negatively impact the quality and price of pharmaceutical supplies,
and thus affect universal health coverage.
To identify the procurement practices that contribute to inefciencies and corruption in
tertiary-level facilities in Nigeria. We examined the procurement process across 2 tertiary-level
health facilities in Nigeria, seeking to current practices that drive inefciencies and corruption.
Participants were staff directly or indirectly involved in the procurement process. They included
2 key administrative staff, pharmacists (n = 13), physicians (n = 5) and drug sales representatives
that bid to supply pharmaceuticals (n = 10) to the health facilities. In-depth interviews were
conducted using an interview guide. Interviews were audio recorded and transcribed.
Transcribed text was analysed using thematic analysis.
There were no comprehensive guidelines for pharmaceutical procurement across the facilities.
Respondents who were not in the procurement committee doubted the transparency of the
procurement process as they had limited information about the standard procedures. Even
though respondents indicate that an open bidding system is in place across the facilities
studied, practices that drive inefciency/corruption abound. Because pharmaceutical
procurement is prescription driven, sales representatives of pharmaceuticals target and
inuence doctors and procurement ofcials with gifts/bribes to prescribe or recommend
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
their specic brands. Procurement committee in one of the facilities allowed the use of brand
names in bidding citing the avoidance of fake and substandard drugs. Sales persons also seek
to inuence key members of the procurement committee to get privileged information and
treatment in the bidding process. Emergency procurements, which was quite common during
the COVID-19 pandemic, gave committee members discretionary powers to by-pass standard
procurement protocols, which then gives opportunity to sometimes favor specic bidders.
A documented guideline for pharmaceutical procurement is required in facilities, and
awareness of the process should be beyond the procurement committee. The use of generic
names in procurement should be encouraged. In cases where fake or substandard drugs pose
problems, quality control mechanisms could be used to identify and include a list of quality
brands to retain bidding competitiveness.
, North-West University, Makeng, South Africa
Vaccine hesitancy remains a major public health concern in the effort towards addressing
the COVID-19 pandemic. This study analyzed the effect of indicators of compliance with
preventive practices on willingness to take COVID-19 vaccines in Kenya. The data were from
the COVID-19 Rapid Response Phone Surveys that were conducted between January and
June 2021 as the fourth and fth waves. The data were analyzed with the random-effects
endogenous Probit regression model, with estimated parameters tested for robustness and
stability. The results showed that willingness to take vaccines increased between the fourth
and fth waves. Compliance with many of the preventive practices also improved, although
utilization of immune system promoting practices were very low. The panel Probit regression
results showed that compliance indicators were truly endogenous and there was existence of
a random effects. Immune system boosting and contact prevention indicators signicantly
increased and reduced willingness to take vaccines, respectively (p<0.01). Experience of mental
health disorder in the form of nervousness signicantly inuenced vaccine hesitancy (p<0.01).
Willingness to take vaccines also signicantly increased among older people and those with
formal education (p<0.01). Different forms of association exists between vaccine hesitancy and
the prevention compliance indicators. There is the need to properly sensitize the people on the
need to complement compliance with COVID-19 contact prevention indicator and vaccination.
Addressing mental health disorders in the form of loneliness, nervousness, depression,
hopelessness, and anxiety should also become the focus of public health, while efforts to
reduce vaccine hesitancy should focus on individuals without formal education, males and
youths.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Paul Revill2, Pakwanja Twea3, Sakshi Mohan4, Gerald Manthalu3 and Peter C.
Smith5, (1)University of York, Addis Ababa, Ethiopia, (2)Centre for Health Economics, University
of York, York, United Kingdom, (3)Ministry of Health, Lilongwe, Malawi, (4)Center for Health
Economics, University of York, York, United Kingdom, (5)University of York, York, United
Kingdom
Universal health coverage (UHC) requires that local health sector institutions—such as local
authorities—are properly funded to full their service delivery commitments. In this study,
we examine how formula funding can align sub-national resource allocations with national
priorities. This is illustrated by outlining alternative options for using mathematical formula to
guide the allocation of national drug and service delivery budgets to district councils in Malawi
in 2018/2019.
We use demographic, epidemiological and health sector budget data with information on
implementation constraints to construct three variant allocation formulae. The rst gives
an equal per capita allocation to each district, and is included as a baseline to compare
alternatives. The second allocates funds to districts using estimates of the resources required
to provide Malawi’s essential health package of priority cost-effective interventions to the
full population in need of each intervention. The third adjusts these estimates to reect
a practicable level of attainable coverage for each intervention, based on the current
congurations of health services and demand for interventions.
Compared with current district allocations, not underpinned by an explicit formula, the
formulae presented in this study suggest sizeable shifts in the allocations received by many
districts. In some cases, the magnitude of these shifts exceed 50% reductions or doubling of
district budgets. The large shifts illustrate inequities in the current system of budget allocation
and the potential improvements possible.
The use of mathematical formulae can guide the efcient and equitable allocation of
healthcare funds to local health authorities. The formulae developed were facilitated by the
existence of an explicit package of priority interventions. The approach can be replicated in
wide range of countries seeking to achieve UHC.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Kamuzu University of Health Sciences, Blantyre, Malawi
Prior to the COVID-19 pandemic, countries in the ECSA-Health Community had introduced
various health nancing reforms in order to achieve Universal Health Coverage (UHC) as a
response to increased disease burden and growing demand for quality health services, amidst
limited economic resources, and high population growth rates.
Document and share experiences across the region in regard to health nancing reforms for
achieving UHC so as to avoid common mistakes during and post-COVID-19 pandemic; and also
learn from best practices across the region that could be used to make health system more
resilient during and post COVID-19 pandemic.
A scoping review of peer reviewed manuscripts and grey literature; and key informant
interviews in regard to three key health nancing policies for achieving UHC: removal of user
fees in public facilities, implementation of national health insurances schemes, and innovative
nancing mechanisms. Data were analysed using the WHO framework of health nancing
function (2000): revenue collection, pooling, and purchasing; and further expounded by two
other frameworks: McIntyre framework (2007): feasibility, equity, efciency, sustainability; and
Walt & Gilson framework (1994): Policy Analysis Triangle – content, process, actors, and context.
User fees removal in public facilities, although there are likely to have been some benets, the
process was characterized by haste, inadequate planning, and policy inconsistence leading to
serious challenges including deteriorating quality of care. Further, the equity impact on the
poor was mixed; mainly with little change in catastrophic/impoverishing spending among
the poor and continued overcharging of unofcial user charges, none availability of funds to
pay for the free care, and still with long distances to travel to health facilities in rural areas.
The implementation of national health insurance schemes were found to be unfeasible –
failing to increase coverage through use of voluntary approach to informal sector employees;
exacerbated inequities in nancing and utilization of health services; inefcient with
multiple pools and high administrative costs; and unsustainable. Some innovative nancing
mechanisms, were found to be an efcient and sustainable source of health nancing in times
of nancial crises.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Much as each country’s context and identied reform is unique, the experience of ECSA-Health
Community provides valuable lessons as to what could be implemented or avoided during and
post COVID-19 pandemic in order to achieve UHC. Sharing of experiences on successes and
missteps could aid countries in navigating the potential complications in implementing health
nancing reforms.
1, Francis Kintu2, Boniface Okuda2, Freddie Ssengooba3 and Christine K.
Tashobya1, (1)Makerere University School of Public Health, Kampala, Uganda, (2)Department
of Research Services -Parliament of Uganda, Kampala- Uganda, Kampala, Uganda, (3)School
of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
1Francis Kintu2, Boniface Okuda2, Freddie Ssengooba1 Christine K.
Tashobya1.
Inadequate funding for health remains a crucial constraint facing the health sector in many
developing countries. The situation is not unique to Uganda, given the country’s commitment
to achieving Universal Health Coverage (UHC). This has generated debate among health sector
policymakers, managers, and civil societies who have urged that low budget allocations have
resulted in poor health services quality and coverage. Tracking nancing trends is crucial to
inform policy and advocacy efforts, especially in the advent of the COVID-19 pandemic.
This study analyzed trends in the health sector funding, emphasizing budgetary allocations
for FY 2010/2011-FY2018/19 to inform policymakers, particularly Members of Parliament, about
the interventions and alternative strategies to nance the health sector for the achievement of
UHC.
Financial data was extracted from different government documents and analyzed descriptively
using Microsoft Excel to summarize data into various tables and graphs. Stakeholder validation
through a workshop was conducted. The implications of the budget trends to health services
delivery elicited from the documents and workshop deliberations were analyzed thematically.
The government budget allocation to the health sector was low, with per capita allocation
(USD17.85) far below the minimum US$84 per capita recommended by WHO. The government
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
contribution to the total health expenditure was dismal at 15.7%. Fluctuations were noted over
time, mainly explained by changes in government funding priorities towards infrastructures
and energy sectors. The low budget allocation manifested as 1) inadequate and poorly
motivated health workers and b) stockouts of essential drugs. These nancing gaps reportedly
contribute to poor access to services, increase catastrophic health expenditures and
undermine national UHC efforts.
Several policy considerations for stronger health systems include a substantial and sustained
increase in the government health budget, optimizing the available resources by addressing
wastages and prioritizing health promotion. The inuence of the COVID-19 pandemic on the
health nancing should be explored. Reforms such as the national health insurance scheme
should be pursued to address nancial risk protection gaps especially related to the ongoing
COVID-19 pandemic.
Budget allocations, health nancing, Universal Health Coverage, Health Service
Delivery, COVID-19.
1, Godefroid Mayala2, Basile Yangala3, Pascal Ngoy4, Body Ilonga5 and
Richard Matendo2, (1)Ministry of Health, Lualaba Province, Kolwezi, Congo (The Democratic
Republic of the), (2)USAID, Kinshasa, Congo (The Democratic Republic of the), (3)Integrated
Health Project/USAID, Kinshasa, Congo (The Democratic Republic of the), (4)Integrated Health
project/USAID, Kinshasa, Congo (The Democratic Republic of the), (5)National Ministry of
Health, Kinshasa, Congo (The Democratic Republic of the)
The DRC health system, organized thru its 26 provinces, is under reforms that aim at improving
the health sector performance through decentralization. Timely deployment of the necessary
resources is a key action to achieve expected results. To improve the resources allocation,
Stakeholders at the provincial level agreed to plan together and to cover specic budget lines
to avoid duplication. Emphasis on increased domestic resources is also part of this contract.
The Contrat unique, an innovative nancial approach, represents a virtual basket fund putting
together all identied stakeholders’ nancial resources to implement the annual provincial
operational plan of the health provincial division through predictable and secured funds from
nancial and technical partners including the government counterpart.
To assess the implementation of the contrat unique in Lualaba province (121,308 km²; 2,570,000
inhabitants in 2020) between 2017 and 2021 and evaluate the progress of the domestic
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
resources’ contribution.
Identifying the proportions of partners’ contributions in relation to the total contract budget
and the trends made over time. Grouping partners according to their afliations and tracing
resources according to their origin. Tracking funds disbursement and/or other related
indicators as health performance improvement, the assessment of the level of commitments’
achievements as included in the contrat unique by the various stakeholders.
Resources allocation doubled in four years (2017-2021), increased from $1,002,650.7 up to
$2,585,301.8. However, failure to capture all partners’ disbursements due to poor coordination
and communication.
Stakeholders’ resources allocation in Lualaba Province, 2017-2021 (Graph 1)
Percentage of disbursement over the time, on quarterly basis (Graph 2)
1. Overall resources allocation increased over the time along with the decentralized entity’s
contribution.
2. Even the level of resources remains low at the provincial level, the contrat unique as an
instrument of health reforms succeeded to draw the attention of the local government
in its role in health budget planning and contribution.
3. Further efforts of coordination are needed to improving funds disbursement and
tracking.
4. The effect of the Covid-19 in the provincial budget allocation and disbursement needs
further evaluation.
Page 115
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
James Avoka Asamani2, Adam Ahmat1, Sunny Okoroafor1 and Jennifer Nyoni1,
(1)World Health Organization, Brazzaville, Congo, (2)World Health Organization, Harare,
Zimbabwe, Christmal Dela Christmals2 and Gerda Marie Reitsma2, (2)North-West University,
Potchefstroom, South Africa, Adam Ahmat2, Jennifer Nyoni2, Juliet Nabyonga-Orem2, (2)
World Health Organization, Brazzaville, Congo.
Africa has faced and continue to face signicant health threat amidst a myriad of health
system weaknesses to respond to the threats adequately. The health workforce (HWF)
continues to be one of the weakest links in the health systems in Africa. Before the pandemic,
it was projected that by 2030, Africa would face a shortage of 6.1 million doctors, nurses, and
midwives, but sadly, some 29% of trained health workers could be either unemployed or
underemployed - a phenomenon of paradoxical surplus that is already hard-hitting many
countries, such as Lesotho, Ghana, Kenya, and Ethiopia.
The speed with which health systems may recover from the protracted COVID-19 pandemic
is hinged on the contribution of its health workers and the investments made in them. More
than 2,000 health workers in the African region[1] have died of COVID-19 by the third quarter of
2021, contributing to a reduced stock of health workers, weakening health systems’ capacity to
respond to the disease. The economic shock imposed by COVID-19 and its response measures
adopted by countries has also constrained both governments and the private sector’s ability
to mobilize resources and expand scal and nancial space to recruit newly trained health
workers. This has exacerbated the unemployment and out-migration of health workers amidst
the COVID-19 situation, which instead required more health workers to be recruited and
retained.
Addressing the pre-pandemic and pandemic related HWF challenges in Africa requires a
good understanding of the dynamics of the challenges and a paradigm shift in making the
HWF an investment priority. This organized session will present ve (5) papers from various
pieces of analytical work undertaken by the HWF unit of the Universal Health Coverage – Life
Course Cluster of Africa Regional Ofce of the World Health Organization to make a case for
better planning to investing to vert the current and looming HWF crisis and shaping the health
workforce for the future in Africa.
[1] The impact of COVID-19 on health and care workers: a closer look at deaths. Health
Workforce Department – Working Paper 1. Geneva: World Health Organization; September 2021
(WHO/HWF/WorkingPaper/2021.1). Licence: CC BY-NC-SA 3.0 IGO.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Adam Ahmat1, James Avoka Asamani2, Sunny Okoroafor1 and Jennifer Nyoni1, (1)World Health
Organization, Brazzaville, Congo, (2)World Health Organization, Harare, Zimbabwe.
African countries have made modest gains in their health indicators, which the role of the
health workforce (HWF) cannot be overstated. However, the evolving health needs of the
population and the need for resilience against acute and chronic shocks continue to strain the
existing HWF. This paper provides deep insights into the state of the health workforce in Africa
and offers considerations for developing the future workforce.
The Africa Regional Ofce of the World Health Organization conducted a HWF survey in
47 Member States between 2018 and 2020. It covered HWF stock, distribution, training,
recruitment, and working conditions, among others. To address the varying nomenclature
of occupations/cadres HWF occupations in different countries, the International Standard
Classication of Occupations (ISCO-08) was used to harmonize occupation classication for
the analysis. Using the updated dataset, various estimations of the HWF was made.
The Africa region have 3.6 million HWF (of all cadres/occupations) or approximately 3.6 health
worker per 1,000 population – 1,315,801 nurses/midwives, 372,236 community health workers
334,167 medical doctors, 370,104 laboratory technicians, 94,098 pharmacists, and 45,047
dentists. Nine countries (19%), each of them had more than 100,000 health workers, but seven
countries (~15%) had less than 5,000. Africa’s HWF stock is increasing by 12% per annum, but
nurses and doctors are at rates lower than the average. The private sector contributes 45% of
the training of HWF but less so (only 12%) of their employment. Nine countries (19%) had more
than 2.28 density of doctors, nurses, and midwives per 1000 population (the MDG minimum
density threshold), but only four countries (8.5%) had reached the SDG density threshold of
4.45 per 1000 population. Considering all health workers (excluding health managers and
support staff), the average regional HWF density was 2.9 per 1,000 population, but 13.4 was
determined to be necessary for the progressive realization of at least 70% of the UHC targets
(10.9 if CHWs are excluded), a benchmark that only Seychelles had met. There was an increase
in the number of health workers recruited in the public sector from 48,482 in 2015 to 89,763 in
2016, but a 14.5% decline to 76,693 in 2017. The highest decrease in recruitment was observed
for nurses and midwives.
The HWF stock and density in Africa is improving but at a pace that still leaves the region
vulnerable. More signicant investment is needed to address gaps and disparities within and
across countries.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
James Avoka Asamani1, Christmal Dela Christmals2 and Gerda Marie Reitsma2, (1)World
Health Organization, Harare, Zimbabwe, (2)North-West University, Potchefstroom, South
Africa
The health workforce (HWF) is critical for developing responsive health systems that address
routine population health needs and respond to health emergencies, including outbreaks
and pandemics. However, defective health workforce planning has been the weakest link in
health systems planning over the years. One approach that is valid for HWF planning is the
population needs-based method. This method combines the population’s health status with
professional standards of care and measures of health worker productivity to determine the
number and calibre of health workers needed to serve the population and the associated
cost. Methodological gaps and lack of simple tools limited its real-life application for policy
and planning. Ghana’s HWF density has improved signicant since 2005 but inequitable
distribution, shortages of some cadres and unemployment of other remain pertinent
challenges, which need-based analysis was used to explore.
We conducted a systematic scoping review of empirical applications of the need-based HWF
planning approach. We synthesized six critical considerations that we built upon to develop a
conceptual and empirical model with accompanying open-access Microsoft® Excel-based tool.
We triangulated data from multiple sources to systematically apply the model to forecast the
needs and supply of HWF in Ghana.
This paper will discuss the imperative of a need-based approach for health workforce
planning to address current and future disease burdens, including health emergencies. The
underpinning conceptual and empirical framework, end-user tools, data requirements and
processes for its application will be discussed with demonstrations. An applied example from
Ghana demonstrated that the health professional’s stock meets about 74% of the overall
need in 2020, but a gap of 26% persisted, which translated into 51,841 health workers across 11
occupations. Without any corrective intervention, the supply will be 77% of the needs by 2030,
with an absolute shortage of 83,657. Beneath the aggregate are huge imbalances as the supply
of 5 out of the 11 health professionals (~45.5%) cannot meet even 50% of the needs by 2035,
but enrolled nurses and midwives seem overproduced. About US$ 2.7 billion, investment is
required in education and employment to correct the projected mismatches by 2035, without
which inappropriate skill mix and unemployment of trained health workers will be enormous.
A need-based approach to health workforce planning promotes equity and support the
attainment of UHC. Ghana’s case study showed that it could be used to generate t-for-
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
purpose evidence for making a case for health workforce investments.
James Avoka Asamani1, Sunny Okoroafor2, Adam Ahmat2, Jennifer Nyoni2, Christmal Dela
Christmals3 and Juliet Nabyonga-Orem2, (1)World Health Organization, Harare, Zimbabwe,
(2)World Health Organization, Brazzaville, Congo, (3)North-West University, Potchefstroom,
South Africa
The health workforce (HWF) is at the core of ensuring an efcient, effective, and functional
health system. There have been increased calls to raise adequate funding from domestic
sources to make appropriate HWF investments. To generate sustained advocacy towards more
signicant and smatter investment in the HWF, this paper presents a scal space analysis of
twenty countries in East and Southern Africa.
We adapted an established empirical framework for scal space analysis and applied it to
country-specic data triangulated from publicly available datasets and government reports
to model the scal space for the HWF in each of the twenty countries in Eastern and Southern
Africa. Based on current knowledge, three scenarios (business-as-usual, optimistic, and very
optimistic) were modelled and compared.
The business-as-usual scenario analysis shows that the cumulative scal space across the
20 countries was estimated to be US$12.09 billion, likely to increase by 29% to US$15.6 billion
by 2026. This is likely to be highest in Kenya (83%) and Tanzania (82%), but a decline by 10% is
expected in Zambia. Under optimistic assumptions (assuming that economies will grow as
projected and health expenditure as a proportion of GDP will increase by 1.5%), the cumulative
scal space would increase by 39% from US$12.09 billion to US$16.82 billion by 2026. Thus,
allocating an additional 1.5% of GDP to health even without further prioritizing the proportional
allocation to the wage bill could boost the cumulative scal space by US$4.73 billion. In a
very optimistic scenario (assuming economics will grow as projected, health expenditure as
a proportion of GDP will increase by 1.5%, and HWF will be highly prioritized within the health
expenditure), the cumulative scal space for HWF is estimated to increase by US$6.35 billion
to US$18.45 billion by 2026. This scenario could improve the scal space for HWF by some
53% over ve years, ranging from 28% in South Africa to 361% in Lesotho. However, Zambia is
estimated to record a decline of 3% still.
Unless the HWF is sufciently prioritized within the health expenditure budget, only
increasing the overall health budget to recommended levels will still leave the HWF heavily
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
underinvested, with growing unemployment amidst unabating shortages with dire
consequences for quality health service delivery.
James Avoka Asamani1, Sunny Okoroafor2, Adam Ahmat2 and Jennifer Nyoni2, (1)World
Health Organization, Harare, Zimbabwe, (2)World Health Organization, Brazzaville, Congo
Amidst a looming shortage of 6.1 million health workers by 2030, Africa’s lingering health
workforce crisis has been compounded by rising unemployment among skilled health workers
as 20 – 30% of the trained health workers in Africa fail to nd appropriate jobs one year after
graduation. In large part, the challenges are linked to rigid scal policies and insufcient
budgetary prioritization for HWF investments culminating in a little room for expanding
employment, exacerbating the out-migration of highly skilled health workers. This paper
demonstrates how countries can translate labour market evidence into policy action for better
investment in the HWF.
From 2017, WHO used state-of-the-art normative approaches to support 16 countries
to conduct comprehensive or partial health labour market analyses (HLMA). Different countries
took different courses of action (depending on their specic ndings and context) and are
at various stages of implementation; some have used it for advocacy and policy action that
unlocked opportunities to invest more and smartly in the HWF.
Several countries moved from evidence to concrete policy action that yielded increased
investment and/or prioritization of the HWF. For instance, Rwanda moved from evidence
generation to action by using the HLMA to contribute to a 10-year HWF development plan
and expanding the number of approved posts for health workers. The budget of the Ministry
of Health in Ghana was increased to employ about 54,000 unemployed health workers, based
on labour market evidence. In 2018, Mali used HLMA evidence to mobilize external resources to
recruit more staff for PHC facilities. The Ministry of Health and Social Services in Namibia used
HLMA to justify the return on HWF investments, resulting in adopting a new structure and
increasing budgetary allocation to recruit additional 300 unemployed doctors and nurses and
pharmacists. In Lesotho, the outcome of the HLMA 2021 was used to inform a 10-year strategy
and to justify a request for a 15% increase in health workforce budgetary increase to absorb 27%
of trained but unemployed health professionals.
Experiences from several countries in Africa have shown that HLMA is a powerful tool
for generating state-of-the-art evidence towards policy and strategic dialogue in HWF
investments.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Sunny Okoroafor1, James Avoka Asamani2, Adam Ahmat1 and Jennifer Nyoni1, (1)World Health
Organization, Brazzaville, Congo, (2)World Health Organization, Harare, Zimbabwe
The COVID-19 outbreak has execrated the persistent health workforce issues in the health
system of the Africa Region. The pandemic has put pressure on health managers in balancing
the availability of health workers with the necessary capacities to meet the high demand for
response activities to ensure health security, as well as sustain the provision of quality essential
health services towards achieving universal health coverage (UHC). This study explored the
innovative strategies implemented by 16 countries in the Africa Region to enhance the health
workforce performance in the course of responding to the COVID-19 pandemic and sustaining
delivery of quality essential health services.
We conducted a document review of 16 country case studies on the impact of COVID-19 on
the health workforce. These case studies were developed from January to August 2021 using
a mixed-method approach with qualitative and quantitative data obtained through semi-
structured interviews and review of national documents on health security, COVID-19 response
and continuity of essential health services.
The 16 countries - Angola, Burkina Faso, Chad, Eswatini, Ghana, Guinea, Guinea Bissau, Ivory
Coast, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal and Togo – implemented
preparedness and response activities to ensure optimal performance of the health workforce.
This included joint planning with the Human Resource Departments to fast-track attraction,
recruitment and deployment activities, and development of incentives to motivate health
workers. All the countries collaborated with Public Health Institutions in the development
and conduct of competency-based in-service trainings to build the capacity of health workers
in risk assessment and case management of COVID-19. Some countries also partnered with
the private sector and other partners (civil society organizations, development partners, non-
governmental organizations, professional bodies and religious and traditional institutions).
They leveraged their human resource expertise and facilities in increasing access to
COVID-19 management services, increasing funding for response activities, expanding risk
communication on COVID -19, fostering community participation in response activities, and
ensuring continuity of essential health service provision in facilities.
Health workers are critical in achieving health security and UHC, and achieving both requires
coordination and partnership with relevant stakeholders at all levels. The approaches applied
by countries in ensuring optimal health worker performance are also pertinent post- COVID
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
and relevant in ensuring the health system resilience. By extension, they are also fundamental
in ensuring global health security and the achievement of UHC in Africa.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Susan Sparkes, World Health Organisation, Chambesy, Switzerland. Diane Karenzi
Muhongerwa WHO/AFRO, Alexandra Earle, WHO Ama Pokuaa, University of Ghana, Accra,
Ghana, Christabell Abewe, WHO Uganda Country Ofce, Kampala, Uganda, Ghada Muhjazi,
WHO EMRO, Cairo, Egypt, Juliet Nabyonga, World Health Organization, Harare, Zimbabwe.
The COVID-19 pandemic has exposed the underlying weaknesses and fragility of health
systems. This fragility stems not only from underinvestment, but also from the way in which
investments (both donor and domestic) have been channeled to support health objectives.
Programmatically oriented investments that focus on single objectives often at the expense
of overall system strengthening have been shown to be neither efcient nor adaptable. As
emerging threats arise, whether from pandemics, climate change, or other health problems,
health systems and the nancing that underpins them, will need to be exible and nimble to
protect and respond.
Given these realities, no country can afford to manage resources inefciently. All resources
need to be used across the system to meet immediate health needs, while preparing and
adapting to future demands. This session will focus on these adaptations in how funds are
channeled, and systems are organized to promote efciency, sustainability, and adaptability.
Evidence generated through country studies will form the basis of the presentations and
related discussions. This concrete evidence about the costs of fragmentation is needed to
identify opportunities for reform that can improve the efcient use of resources in a way that
best aligns with overall health system-level objectives and needs.
The session will present three papers that assess specic aspects of the efciency agenda in
Ghana, Uganda, and Sudan. The range of these papers highlights different perspectives and
issues that can inhibit the efcient use of available resources. These relate to political dynamics,
the way in which donor funds are channeled and managed, and to how to balance short-term
demands associated with COVID-19 in relation to the overall health system dynamics. It will
then pull out the key lessons based on the implementation of cross-programmatic efciency
analysis from seven African countries to highlight cross-cutting areas of undue fragmentation,
misalignment, and duplication. The last paper will provide a synthesis of opportunities and
constraints to addressing the types of inefciencies that are discussed and presented in the
other papers in the session.
The complete set of papers will provide concrete evidence as to where and how efciency
can be improved at the system-level to align health nancing towards more resilient and
sustainable systems and related outcomes.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Ama Pokuaa, University of Ghana, Accra, Ghana
COVID-19 brought in its wake unprecedented disruptions. Different countries have managed
this challenge differently. From government-imposed restrictions such as quarantines, border
closures, workplace closures and social distancing rules to slow the rate of transmission
and deaths associated with the pandemic. In Ghana, the national response to the COVID-19
pandemic was initiated when the rst two cases were reported on the 12 March 2020. The
Government’s response to the pandemic was mainly inuenced by lessons learnt from some of
the countries, which were earlier affected by COVID-19, such as those in Asia and Europe. This
was outlined in the National COVID-19 Emergency Preparedness and Response Plan (EPRP)
which was largely funded with the US$100million (GH¢560 million) from the World Bank.
Inspired by the signicant successes from the implementation of the EPRP and considering
the lasting impact of the pandemic within the medium-term, the government has rolled
out a more holistic plan which is the ‘National Strategic COVID-19 Response Plan: July 2020 -
December 2024’ (NSCRP) (Ministry of Finance, 2021).
These developments have presented constraints on government nances, with increased
government expenditures due to COVID-related spending. Additionally, the health system has
not been robust enough to deal with the increasing pressure on hospital facilities, especially
the lack of medical laboratories in the country, where effective research and placebo testing
could be done.
The study uses Cross-Programmatic Efciency Analysis (CPEA) related to the delivery of
COVID-19-related services and interventions within the context of the overall health system.
It uses both qualitative and quantitative methods that are anchored in the analysis of health
system functions (nancing, service delivery, governance/stewardship, and generation of
human and physical resources/inputs). The main aim is to identify targeted and feasible
options where existing resources and functions can be used, strengthened, and sustained
for Ghana’s COVID-19 response, as well as where additional resources may be needed. This
assessment focuses on effective and efcient delivery of COVID-19 tools that minimize
potential distortions on other essential health services. It will also highlight how coordination
with other health sector priorities and reform processes have performed.
This system-wide analysis will engage stakeholders across the health sector and beyond
to prioritize and develop policy options to reduce areas of duplications, overlaps and
misalignments that impact the efcient and effective use of available resources. The ndings
from this analysis will also have direct implications for sustainability of programmes that rely
on external assistance.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Christabell Abewe, WHO Uganda Country Ofce, Kampala, Uganda
Universal health coverage ensures affordable access to high-quality health services for all;
however, this will inevitably require governments to nd additional budgetary resources
and to increase the scal space for health. While there are a number of ways of increasing
health sector resources, recent attention has been directed to increasing the efciency in the
use of available health resources. This is especially relevant in Uganda where the nancial
contributions by development partners in health have been declining steadily over the past
years, specically in priority health programs. As Uganda aspires to attain higher middle-
income status by 2040 and is transitioning away from donor eligibility, there is a need to
identify mechanisms to increase efciencies in the current resource allocation. As such, the
HIV/AIDS, TB, Malaria, RMNCAH, and EPI programs, all programs that rely heavily on external
aid, will be analyzed in the context of the overall health system to identify areas of inefciencies
that constrain the ability of the government to deliver priority health services to the population
to meet health system objectives.
Data collection for this analysis comes qualitative data gathered from key informant interviews
and meetings with relevant stakeholders through the use of a semi-structured interview
guide. Quantitative data will be collected for nancial budget and expenditures, inputs
(facilities, health workers, medicines, etc.), health services, outputs, and outcomes using
nationally available data as well as from SHA11 National Health Accounts via the Global Health
Expenditure Database. Data will be collected at the national and sub-national level wherever
possible. Data collected is rst organized by health system function (nancing, service delivery,
governance/stewardship, and generation of human and physical resources/inputs) across the
selected health programmes. An across function analysis can then be conducted to identify
specic areas inefciency that constrain the achievement and sustainability of objectives.
from this analysis show the following identied inefciencies:
• Separate information systems across health programs
• Multiple disease-specic donor funding streams
• Fragmented human resources salary support mechanisms
• Disjointed and weak supervision regimes across the health system
• Dysfunctional referral mechanisms
• The budget and planning process for health programs are not aligned with overall
health sector processes.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Ghada Muhjazi, WHO EMRO, Cairo, Egypt
The Eastern Mediterranean Regional Ofce (EMRO) of the World Health Organization has
commissioned case studies of sustainability and transition for Global Fund-supported HIV,
Tuberculosis (TB), and Malaria (HTM) programs to maintain or increase the gains made in these
countries. In Sudan specically, the case study will focus on strengthening sustainability with
their HTM programs as part of the overall health system with the aim to provide options for
action with moving forward. The results also will serve as input into EMRO’s draft guidance for
countries in the region to initiate early planning for sustainable programs towards a successful
transition from Global Fund support to maintain and accelerate gains against priority diseases.
Data collection will consist of conducting key informant interviews and reviewing key
documents as well as country nancial data on macro-economic and programmatic level
indicators. Quantitative data will be gathered from the Global Fund co-nancing data
submitted in country applications, as well as through SHA2011 National Accounts data using
the Global Health Expenditure Database. The quantitative data collected will help to inform the
qualitative data gathered through the interviews.
The ndings from this paper will describe the health nancing context in the country as
well as the current extent of Sudan’s reliance on donor support for their HTM programs. It
will identify priority areas of inefciencies across the health programs and the overall health
system and how those inefciencies constrain the sustainability and delivery of priority health
services. It will end with a list of policy options for action for the sustainability of the donor
supported programs in the country.
Juliet Nabyonga, World Health Organization, Harare, Zimbabwe
In the context of donor transition and as responsibility for funding certain health programmes
shifts more towards domestic resources, maintaining distinct, separate organizational
arrangements by health programme is unlikely to be sustainable. Hence, identifying
duplications and misalignments offers an opportunity to re-congure programmes in a way
that will enhance the ability of national governments to sustain the delivery of priority services
to their populations. To date, this approach has been implemented in 7 WHO/AFRO countries.
Even though analyses varied in terms of the motivation for each study, there are lessons to
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
be learned and shared across these countries on the challenges and opportunities to address
identied inefciencies.
A cross-programmatic efciency analysis was conducted in each of these 7 countries. The core
analysis consisted of mapping and describing each of the four health system functions and
sub-functions for the overall health system and selected health programmes. This mapping
exercise formed the foundation to then identify the critical areas of misalignment, duplication
and overlap across the group of health programmes and with the wider health system.
Through a workshop, which convenes all relevant countries and focal points in the 7 countries,
countries will jointly discuss issues related to how to effectively support reforms to improve
sustainability and efciency. Best practices and highlighted challenges to address will be
the focus of this workshop. A summary of synthesized key ndings that focus on both cross-
programmatic inefciencies identied, as well as the mechanisms to address them will be the
output of this workshop.
• Initial results show the following key ndings and mechanisms to address them:
• Fragmented governance and lack of coordination across health system and health
programmes
• Fragmentation and duplication of resources and inputs
• Disjointed nancial ows leads to uncoordinated programme activities and personnel
• Embed analysis within broader health sector reform processes and health
strengthening efforts.
Susan Sparkes, World Health Organisation, Chambesy, Switzerland
Many health systems rely on health programmes to target health interventions for specic
diseases or populations. These programmes tend to operate largely autonomously from one
another in seeking to optimize the achievement of a specic objective. This organizational
approach can constrain efciency and the evolution of the health system in its ability to adapt
to changing morbidity patterns, technological advances, among other issues. Through its
application in 7 African countries to date, analysis and data-informed dialogue has been built
across programme- and system-components around specic areas for improved integration
and coordination to improve efciency and enable outcomes. Building from this foundation,
the next phase of this work programme will continue to focus on country support
To identify specic areas of duplication, overlap or misalignment a series of case studies was
developed that uses in-depth health system functional mapping. This work uses a mixture
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
of qualitative and quantitative methods that are anchored in the analysis of health system
functions (nancing, service delivery, governance/stewardship, and generation of human and
physical resources/inputs) across a set of health programmes within each of 7 countries. Once
the within program system mapping is completed, an across function analysis is conducted
to identify specic areas inefciency that constrain the achievement and sustainability of
objectives. Comparative analysis based on the common methodology applied in each country
is then used to develop key cross-cutting ndings.
show that four key areas of cross-cutting inefciency have been identied:
• Uncoordinated planning and budgeting processes
• Fragmented inputs (information systems, laboratories, health workers, facilities)
• Misaligned nancing mechanisms with service delivery objectives
• De-linked programmatic objectives and priorities from overall health sector reforms
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Agnes Gatome-Munyua Results for Development (R4D) Obinna Onwujekwe
University of Nigeria, Enugu campus, Health Policy and Research Group, Oludare Bodunrin
Strategic Purchasing Africa Resource Center (SPARC),Cheryl Cashin Results for Development
Joël Arthur Kiendrébéogo, Recherche pour la Santé et le Développement (RESADE),
Ouagadougou, Burkina Faso, Umuhoza Stella Matutina, University of Rwanda, College
of Medicine and Health Sciences, School of Public Health, Kigali City, Rwanda, Uchenna
Ezenwaka, University of Nigeria Nsukka (Enugu Campus), August Kuwawenaruwa, Ifakara
Health Institute, Dar es salaam, Tanzania
The COVID-19 pandemic has demonstrated the imperative for strong health systems, that
are resilient, effective, and equitable to provide the best care possible to its population.
Strategic purchasing aims to make the best use of resources by making evidence-based
decisions on what to buy, from whom to buy and how to buy to improve population health
and achieve universal health coverage (UHC). Evidence on current purchasing arrangements
in sub-Saharan Africa (SSA) and how they lead to improvements in health systems is sparse.
The Strategic Purchasing Africa Resource Center (SPARC) and eleven African partners co-
created the Strategic Health Purchasing Progress Tracking Framework to create a snapshot
of purchasing functions across health nancing schemes and their intended and unintended
effects on purchasers and providers.
The framework maps the governance arrangements and external factors inuencing
purchasing, and delves into the core purchasing functions of benets specication,
contracting arrangements, provider payment and performance monitoring. The partners
applied an excel based tool based on the framework in nine SSA countries to collect baseline
data via document review and key informant interviews to identify where countries are making
progress to improve purchasing.
The nine countries have diverse and fragmented health nancing systems, including
government budget– nanced schemes, private and social health insurance, and donor-
funded programs, each with their own purchasing arrangements. There is some progress in
benets specication and developing contracting arrangements - particularly with private
sector providers. There is least progress in developing out-put based payment mechanisms
linked to service delivery objectives and using performance monitoring to incentivize
productivity and quality health services. Fragmentation reduces the pool of funds managed
by each purchaser and reduces their leverage to improve resource allocation, provide the right
incentives to providers and create accountability for quality health services.
Reducing fragmentation is a critical enabler for strategic purchasing and to improve the
performance of health nancing systems for health system resilience. The partners are using
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
the results to initiate dialogue on how to improve strategic purchasing, make health nancing
systems more resilient, and put countries on a sustainable trajectory to UHC.
SPARC proposes an organized session for SPARC partners from Burkina Faso, Rwanda,
Tanzania and Nigeria to share their experience applying the framework, discuss lessons and
provide reections to continue progress in the post-COVID era. This session will also launch a
Health Systems and Reform Journal special edition. This session will be offered in English with
simultaneous French translation�
Joël Arthur Kiendrébéogo, Charlemagne Tapsoba, Yamba Kafando, Issa Kaboré, Orokia Sory,
S. Pierre Yaméogo
Strategic health purchasing (SHP) is seen as a key strategy to spur countries’ progress
toward universal health coverage (UHC). Countries have unique contexts that shape existing
purchasing arrangements and contribute to incremental change. In this session we present
ndings from mapping purchasing and governance arrangements in ve key health nancing
schemes in Burkina Faso – Gratuite, Transferred Credits, Delegated credits, Occupational
health insurance and Mutuelles.
Our analysis is guided by the Strategic Health Purchasing Progress Tracking framework for
tracking progress in purchasing developed by Strategic Purchasing Africa Resource Centre
and its partners. Data were collected from June–December 2019 through a document review
that was complemented by in-depth interviews. Data were analyzed manually to examine
governance arrangements, purchasing functions and capacities, including their strengths and
weaknesses.
The market structure for all ve health nancing schemes precludes competition among
purchasers and providers. The level of purchaser autonomy is mixed, but legal and regulatory
frameworks clearly specify roles and responsibilities and ensure proper implementation of
purchasing functions. Many accountability mechanisms have been implemented, but they are
poorly coordinated and often depend on external funding, which limits their effectiveness and
jeopardizes sustainability. The capacity for selective contracting, reviewing of benet packages,
and modifying of provider payment methods varies by scheme.
Benet packages are in place, but the design of these benet packages does not consider
citizen preferences, and contracts are not linked to explicit quality standards or treatment
protocols. For all schemes, payments are linked to the volume of services provided, which is
treated as a proxy for performance. The information used to pay providers is easy to access and
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
analyze, but it is not disaggregated by individual patient. No specic measures are in place
to sanction poor performance. Dissemination of information on the rights and obligations of
citizens varies by scheme and mechanisms exist for collecting and responding to complaints
and feedback from beneciaries on the quality of care, but there is room for improvement.
s
Although there has been progress in dening clear mandates, the implementation of
purchasing functions such as benets specication, contracting arrangements, performance
monitoring remains weak and requires strengthening. This requires a proactive approach to
regularly evaluate if initiatives implemented to promote strategic purchasing contribute to
achieving UHC goals.
Stella M. Umuhoza, Sabine F. Musange, Alypio Nyandwi, Agnes Munyua, Angeline
Mumararungu, Regis Hitimana, Alexis Rulisa, and Parfait Uwaliraye
Rwanda is a low-income country that is well known for achieving good health outcomes in the
past two decades, at much lower levels of health spending than many other African countries.
In the context of scarce resources and increasing health care costs, strategic purchasing is
viewed as a key mechanism to spur progress toward universal health coverage. We examine
health nancing schemes in Rwanda, by mapping purchasing functions of the Community
Based Health Insurance (CBHI) scheme, the Rwanda Social Security Board (RSSB) medical
scheme, and performance-based nancing to understand where there is overlap, duplication
and conict that hampers progress in strategic purchasing.
The strategic health purchasing progress tracking framework was applied by populating
an Excel–based tool with data collected over seven months (September 2020 to March
2021) through document review complemented by in-depth interviews. We analyzed the
data manually, examining governance arrangements, purchasing functions and capacities,
including their strengths and weaknesses.
Rwanda has a strong regulatory framework with mandates for purchasing and engaging
stakeholders. We identied some overlapping mandates and functions—for example, benet
specication by both the Ministry of Health and the National Health Insurance Council. CBHI
and RSSB schemes have a comprehensive benet package, but the process for benets
specication is not informed by evidence. Schemes use a mix of line-item budget and fee-for
service which bring limited benet to the health system. Mechanisms to monitor provider
performance are used in tandem with provider accreditation to improve quality of care in
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
public hospitals under the PBF program, but these benets do not cascade to the CBHI and
RSSB schemes.
Rwanda’s health system has elements of strategic purchasing, but challenges remain and
there is room for improvement, especially to ensure that benet packages align with the
population’s needs, provider payment that contains cost, and quality assurance.
Uchenna Ezenwaka, Agnes Gatome-Munyua, Chikezie Nwankwor, Nkechi Olalere, Nneka Orji,
Uchenna Ewelike, Benjamin Uzochukwu, Obinna Onwujekwe
Strategic health purchasing enhances health care system performance and attainment of
health system goals through efcient use of nancial resources. Studies on the governance
and institutional arrangements for health purchasing in Nigeria’s health nancing schemes
and how they affect strategic health purchasing are limited. This study investigates the
inuence of governance and institutional arrangements on implementing strategic health
purchasing within the National Health Insurance Scheme’s Formal Sector Social Health
Insurance Programme (FSSHIP) and General Tax Funding (GTF) in Nigeria.
A qualitative, descriptive case study approach was used to collect information on FSSHIP and
GTF schemes. Data was collected through review of relevant documents (20) and interviews
with key informants (n=6) using a structured template, and data analyzed using a thematic
framework approach.
The ndings reveal some governance structures in health purchasing within FSSHIP that
facilitate strategic health purchasing, including systems for designing benet packages,
accrediting and monitoring health maintenance organizations (HMOs) and providers, dening
provider payment mechanisms, and vetting claims. However, purchasing is plagued by
institutional challenges that impede strategic purchasing, including weak regulation, weak
monitoring of providers and purchasers, delays in provider payment, and corrupt practices by
HMOs. GTF schemes have a system for benets specication, contracting with providers, and
budgeting, which enhances strategic purchasing. But purchasing by GTF schemes is impeded
by fragmented benet packages, which leads to inefciencies and duplication of services. The
criteria for resource allocation are unclear and not evidence based.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Capacity to undertake strategic purchasing within the FSSHIP and GTF schemes is limited
due to weak governance and institutional arrangements. The schemes have the potential to
contribute to achieving UHC if these constraining factors are addressed.
Uchenna Ezenwaka, Agnes Gatome-Munyua, Chikezie Nwankwor, Nkechi Olalere, Nneka Orji,
Uchenna Ewelike, Benjamin Uzochukwu, Obinna Onwujekwe
Strategic health purchasing enhances health care system performance and attainment of
health system goals through efcient use of nancial resources. Studies on the governance
and institutional arrangements for health purchasing in Nigeria’s health nancing schemes
and how they affect strategic health purchasing are limited. This study investigates the
inuence of governance and institutional arrangements on implementing strategic health
purchasing within the National Health Insurance Scheme’s Formal Sector Social Health
Insurance Programme (FSSHIP) and General Tax Funding (GTF) in Nigeria.
A qualitative, descriptive case study approach was used to collect information on FSSHIP and
GTF schemes. Data was collected through review of relevant documents (20) and interviews
with key informants (n=6) using a structured template, and data analyzed using a thematic
framework approach.
The ndings reveal some governance structures in health purchasing within FSSHIP that
facilitate strategic health purchasing, including systems for designing benet packages,
accrediting and monitoring health maintenance organizations (HMOs) and providers, dening
provider payment mechanisms, and vetting claims. However, purchasing is plagued by
institutional challenges that impede strategic purchasing, including weak regulation, weak
monitoring of providers and purchasers, delays in provider payment, and corrupt practices by
HMOs. GTF schemes have a system for benets specication, contracting with providers, and
budgeting, which enhances strategic purchasing. But purchasing by GTF schemes is impeded
by fragmented benet packages, which leads to inefciencies and duplication of services. The
criteria for resource allocation are unclear and not evidence based.
Capacity to undertake strategic purchasing within the FSSHIP and GTF schemes is limited
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
due to weak governance and institutional arrangements. The schemes have the potential to
contribute to achieving UHC if these constraining factors are addressed.
Augustine Kuwawenaruwa, Suzan Makawia, Fatuma Manzi
Strategic health purchasing in low and middle-income countries has received substantial
attention as countries aim to achieve universal health coverage, by ensuring equitable
access to quality health services without the risk of nancial hardship. There is little evidence
published from Tanzania on purchasing arrangements and what is required for strategic
purchasing. This study analyses three purchasing arrangements in Tanzania and gives
recommendations to strengthen strategic purchasing in Tanzania.
We used the multi-case qualitative study drawing on the National Health Insurance Fund
(NHIF), Social Health Insurance Benet (SHIB), and improved Community Health Fund (iCHF)
to explore the three insurance schemes with a purchaser-provider split. Data were drawn from
document reviews and results were validated with nine key informant interviews with a range
of actors involved in strategic purchasing. A deductive and inductive approach was used to
develop the themes and framework analysis to summarize the data.
The ndings show that benet specication for all three schemes was based on the standard
treatment guidelines issued by the Ministry of Health. Public facilities are automatically
included in these schemes while there is selective contracting with private facilities based
on the location of the provider, the range of services available as stipulated in the scheme
guideline, and the willingness of the provider to be contracted. NHIF uses fee-for-service to
reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to
monitor registration, verication, claims processing, and referrals. While SHIB monitoring is
through routine supportive supervision and for the iCHF provider performance is monitored
through utilization rates.
Purchasers in the three schemes have made progress in benets specication, selective
contracting of the private sector, claims monitoring. However, use of fee for service as the
predominant provider payment modality in NHIF requires review to improve efciency and
contain costs; while use of output based payment such as capitation by iCHF and SHIB
provides lessons for NHIF for cost containment. As Tanzania considers introducing a single
national health insurance (SNHI), the role of these three schemes needs to be claried, while
considering the strengths and shortcomings to improve on with the redesign of the SNHI�
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Ghana Institute of Management and Public Administration (GIMPA), Accra,
Ghana
The adoption of the Sustainable Development Goal (SDG) 3.8 in the year 2015 has marked
a shift of focus in global and regional discourse on health from elimination or reduction of
specic diseases/conditions to Universal Health Coverage (UHC) - that all people who need
essential health services receive them without suffering from nancial hardship. The outbreak
of the COVID-19 pandemic has made the need for the attainment of the UHC goal more
pressing.
The central objective of this study is to evaluate the performance of health systems of SSA
countries, accentuating the efciency of progress being made to achieve the UHC goal.
UHC indices were estimated for 30 SSA countries using ten health coverage indicators and
two nancial protection indicators. Technical efciency scores were estimated using the
output-oriented variable returns to scale (VRS) data envelopment analysis (DEA) model. This
methodology allows for the evaluation of each country’s ability to transform health inputs
(health expenditure, medical doctors, nurses and beds) into health output (UHC index). The
efciency scores are regressed against seven explanatory variables: education, governance
quality, out-of-pocket payment, domestic health spending, external health funding,
compulsory health nancing arrangement, and income levels using bootstrap DEA proposed
by Simar and Wilson (2007).
The estimated UHC indices range from a minimum of 52% to a maximum of 81%, and medium
coverage of 66%. On average, the health systems of the selected SSA countries have bias-
corrected efciency score 0.872 (95% condence interval = 0.830 – 0.913). The bootstrap
simarwilson regression also revealed that while education, governance quality, domestic
health spending, external health funding, and compulsory health nancing arrangement
have positive signicant effect on health system efciency in making progress towards the
attainment of the UHC goal, out-of-pocket payment signicantly reduces the efciency of
health systems in achieving UHC.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
To improve technical efciency of health systems, policy makers should focus on policies that
empower individuals’ education, good governance, and mode of nancing healthcare rather
than relying solely on providing healthcare services. Policies that enhance education, good
governance, and reduce out-of-pocket payment for health services lead to improved health
system performance which eventually speed up progress towards achieving UHC.
Health Systems, Universal Health Coverage, Technical Efciency, Data Envelopment
Analysis, Sub-Saharan Africa.
1, Osondu Ogbuoji2, Wenhui Mao2, Minahil Shahid2, Obinna Onwujekwe3 and
Gavin Yamey2, (1)Department of Community Medicine,University of Nigeria Teaching Hospital,
Enugu, Nigeria, (2)The Center for Policy Impact in Global Health, Durham, NC, (3)University of
Nigeria, Nsukka, Enugu Campus, Enugu, Nigeria
In the coming years, about a dozen middle-income countries are excepted to transition out of
development assistance for health (DAH) based on their economic growth. This anticipated
loss of external funds at a time when there is a need for accelerated progress towards universal
health coverage (UHC) is a source of concern.
Evaluating country readiness for transition towards country ownership of health programmes
is a crucial step in making progress towards UHC.
We used in-depth interviews to explore: (1) the preparedness of the Nigerian health system to
transition out of DAH, (2) transition policies and strategies that are in place in Nigeria, (3) the
road map for the implementation of these policies and (4) challenges and recommendations
for making progress on such policies. We applied Vogus and Graff’s expanded transition
readiness framework within the Nigerian context to synthesize preparedness plans, gaps,
challenges and stakeholders’ recommendations for sustaining the gains of donor-funded
programmes and reaching UHC.
Some steps have been taken to integrate and institutionalize service delivery processes
toward sustainable immunization and responsive primary healthcare in line with UHC. There
are ongoing discussions on integrating human immunodeciency virus (HIV) services with
other services and the possibility of covering HIV services under the National Health Insurance
Scheme (NHIS). We identied more transition preparedness plans within immunization
programme compared with HIV programme. However, we identied gaps in all the nine
components of the framework that must be lled to be able to sustain gains and make
signicant progress towards country ownership and UHC.
Nigeria needs to focus on building the overall health system by identifying systematic gaps
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
instead of continuing to invest in parallel programmes. Programmes need to be consolidated
within the overall health system, health nancing priorities and policies. A comprehensive and
functional structure will provide continuity even in the event of decreasing external funds or
donor exits.
Development assistance for health; Nigeria; UHC; transition.
, WHO Kenya Country Ofce, Nairobi, Kenya, Puis Wassuna Owino,
Council of Governors, Nairobi, Kenya, Isabel W Maina, Ministry of Health, Nairobi, Kenya,
Jacob Kazungu, KEMRI Welcome Trust, Nairobi, Kenya, Benjamin Nganda, World Health
Organisation, Zimbabwe, Juliet Nabyonga, World Health Organization, Harare, Zimbabwe
and Susan Sparkes, World Health Organisation, Chambesy, Switzerland
Meaningful progress towards Universal Health Coverage (UHC) will depend on more resources
being available to the health sector. However, Kenya’s renewed focus on moving towards UHC
comes at a time when donors are transitioning from directly supporting the health sector.
Kenya’s commitment to UHC provides an opportunity for Kenya to approach donor transition
from a UHC lens so as to ensure sustainability and system resilience. With this background, this
study set out to explore cross programmatic inefciencies in the implementation of priority
health programs that depend signicantly on donors.
Using a cross-sectional design, data was collected through document review and key
informant interviews and at national and in a sample of three counties. The analytical
approach adopted a system-wide approach to analyzing efciency across the selected health
programs. The selected programs were HIV, TB, Immunization, RMNCAH, & Malaria. The
approach included mapping implementation of the programs across the four core functions
of the health system (service delivery, stewardship/ governance, generation of human and
physical resources/inputs and health nancing). Based on this, we map areas of duplication,
overlap and misalignment across the programmes and within the broader health system
aspects related to the programs.
Donor funded programs have multiple funding ows with different incentive structures that
result into misalignment with broader health system goals. On the input side, there is still
program based human resource management leading to duplicative roles, sub optimal staff
performance and over reliance on contracted staff while fragmentation in supply chains
resulting into lack of coordination in supplies and complimentary inputs compromising access
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to health services. There are also challenges observed in terms of multiple data systems and
mechanisms for reporting and data use with the programs. The organization of the health
system functions above including governance also affects effective service delivery including
public health functions.
As countries plan to transition from donor resources while on the path to scaling up UHC,
focus should not just be on aiming at just replacing donor dollars with domestic dollars as this
is neither efcient nor sustainable. Cross programmatic efciency identies potential health
system overlaps/misalignments that could be addressed as Kenya transitions from donor
support so that access to priority services is sustained and the system becomes more resilient.
, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya, Edwine
Barasa, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya and John Ataguba,
University of Cape Town, Cape Town, South Africa
Non-communicable diseases (NCDs) account for 50% of hospitalisations and 55% of inpatient
deaths in Kenya. Hypertension is one of the major NCDs in Kenya. Equitable access and
utilisation of screening and treatment interventions are critical for reducing the burden of
hypertension. This study assessed horizontal equity (equal treatment for equal need) in the
screening and treatment for hypertension. It also decomposed socioeconomic inequalities in
care use in Kenya.
Cross-sectional data from the 2015 NCDs risk factors STEPwise survey, covering 4,500 adults
aged 18-69 years were analysed. Socioeconomic inequality was assessed using concentration
curves and concentration indices (CI), and inequity by the horizontal inequity (HI) index.
A positive (negative) CI or HI value suggests a pro-rich (pro-poor) inequality or inequity.
Socioeconomic inequality in screening and treatment for hypertension was decomposed into
contributions of need (age, sex, and body mass index (BMI)) and non-need (wealth status,
education, exposure to media, employment, and area of residence) factors using a standard
decomposition method.
The need for hypertension screening was higher among poorer than wealthier socioeconomic
groups (CI = -0.077; p < 0.05). However, wealthier groups needed hypertension treatment more
than poorer groups (CI = 0.293; p<0.001). Inequity in the use of hypertension screening (HI =
0.185; p<0.001) and treatment (HI = 0.095; p<0.001) were signicantly pro-rich. Need factors such
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
as sex and BMI were the largest contributors to inequalities in the use of screening services. By
contrast, non-need factors like the area of residence, wealth, and employment status mainly
contributed to inequalities in the utilisation of treatment services.
Among other things, the use of hypertension screening and treatment services in Kenya
should be according to need to realise the Sustainable Development Goals for NCDs.
Specically, efforts to attain equity in healthcare use for hypertension services should be multi-
sectoral and focused on crucial inequity drivers such as regional disparities in care use, poverty
and educational attainment. Also, concerted awareness campaigns are needed to increase the
uptake of screening services for hypertension.
1, Kélath Bello1, Cheickna Touré2, Allison Kelley3, Conrad
Tonoukouen3 and Jean-Paul Dossou1, (1)Centre de Recherche en Reproduction Humaine et en
Démographie (CERRHUD), Cotonou, Benin, (2)Results for Development (R4D), Bamako, Mali,
(3)Results for Development (R4D)
The journey towards universal health coverage (UHC) in sub-Saharan African countries is a
complex process, not just technical, but also highly political. Rigid protocols to address the
identied problems have limited application or are counter-productive. Continuous learning
is key for adapting strategies to the countries’ context and enhancing the chances for
success . Process documentation (PD) is an innovative approach, developed by the African
Collaborative for Health Financing Solutions (ACS), to address this complexity and to support
more effectively countries in their UHC policy processes. This paper aim at presenting the PD
approach and the lessons learnt through its application.
PD is a prospective policy analysis approach which consist in documenting systematically all
relevant events and stakeholders which could potentially inuence or be inuenced by a given
UHC process; analysing them in real-time; and using the lessons learnt to improve the UHC
process. PD follows a ve-steps iterative process including: the identication of the process to
be documented and the documentation team, the recording of events and stakeholders, the
immediate analysis of individual records, the periodic desk analysis of a set of records, and the
integration of the key lessons learnt into the policy process. The PD methodology has been
used by the ACS project in Benin, Botswana, Burkina Faso, Uganda, Namibia, and Togo. Key
achievements include a successful facilitation of the process of developing a UHC roadmap
in Uganda, rapid learning cycles to support the pilot phase of the social health insurance
scheme “AM-ARCH” in Benin, and a stakeholder analysis for supporting the development of a
workplan to accelerate UHC progress in Togo. The experimentation of the PD approach rose
some challenges including the difculty of obtaining reliable and timely information, time
investment from those who document, and managing the stakeholder’s sensitivity, given the
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political nature of some ndings.
In conclusion, PD is a promising approach with the potential to continuously inform policy
processes. There is a need to rene the methodology to make it easier to use routinely and to
improve its effectiveness.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University of Nigeria, Enugu Campus, Enugu, Nigeria, Francis Ayomoh,
Fed Ministry of Health, Abuja, Nigeria and Oludare Bodunrin, Strategic Purchasing Africa
Resource Center (SPARC), Nairobi, Kenya
: Achievement of Universal Health Coverage (UHC) relies on effective implementation of
strategic purchasing for healthcare (SHP) directly linked to enhanced system performance.
Consequently, countries committed to UHC have made progress towards SHP to optimize
attainment of health system goals. The study examined the purchasing practices in the Niger
state healthcare system to assess and identify progress, challenges and opportunities for SHP.
: The study critically analyzed the Niger state’s health nancing schemes to assess their
purchasing practices based on a descriptive qualitative case study approach. Reviews of
relevant documents were undertaken including in-depth interviews with key informants/
stakeholders. Information on external factors and governance, purchasing practices, and other
capacities of the state’s nancing schemes were collected. Data was analyzed guided by the
SPARC recommended framework for examining purchasing practices for progress towards
strategic healthcare purchasing.
: A governance and accountability structure is led by the Commissioner for Health through
the MOH across the departments and agencies with clear lines of responsibilities. The SMOH
is the dominant provider/purchaser of healthcare in the state, with other agencies possessing
purchasing functions. Government commitment towards UHC led to development of policy
and regulatory frameworks for SHP, revitalization of PHC facilities for improved service delivery,
and establishment of the state’s health contributory scheme NICARE, all of which support
SHP objectives. However, budget allocation for healthcare remains very inadequate due to
poor revenue sources, which constrain SHP objectives. As an integrated system, the SMOH
lack purchaser-provider split as providers are not selected based on quality of service delivery
and performance. Provider performance monitoring is weak with limited incentive to drive
performance. Provider payments through salary and line-item budget do not promote quality
and efciency of service delivery. There are no clear channels between the SMOH and the
citizens to provide timely feedback on service delivery. Capacity for strategic purchasing is very
limited but willingness for technical support remains high.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Healthcare purchasing in Niger state remains largely passive given the operation of public
integrated system which portends impediments to SHP. However, signicant progress
has been made towards SHP in the state. Health infrastructure upgrade, establishment of
contributory health scheme among signicant policy and regulatory frameworks represent
major progress towards SHP in the state. Strong government’s commitment towards UHC,
strengthening of the contributory health scheme and availability of technical support, among
other recommended measures will boost implementation of SHP in the state for progress
towards UHC.
, Binta Ismail, Muhammed Muhammed, Muhammed Mashin, Ismail
Salihu and Sarah Martin, National Primary Health Care Development Agency (NPHCDA),
Abuja, Nigeria
Nigeria’s health indices remain among the worst within Sub-Saharan Africa. Progress towards
improving infant, under-5 and maternal mortality rates, and skilled birth attendance also fell
behind international standards. In 2011, the Nigeria State Health Investment Project (NSHIP)
was introduced to shift the focus to strengthening service delivery and improving health
outcomes through innovative approaches to health nancing using -Based Financing
(RBF). NSHIP was then expanded to tackle the disruption to health services caused by the
Boko Haram insurgency in the Northeast Region.
In light of the ofcial closure of NSHIP in 2021, this paper offers the opportunity to reect upon
how the project has evolved over 10 years of implementation, particularly the key challenges
faced and how they were overcome. Available data regarding nance, personnel management,
and local adaptations is worthwhile in informing future programming for RBF projects. Self-
evaluation following NSHIPs closure provides a systematic reection of the results, challenges
and lessons learnt.
The evaluation period was from 2011 to 2020 to collect principal information. Key informant
interviews and NSHIP project documents were used for qualitative data, while primary data
from the project portal and National Health Management Information System was collected
for quantitative review. Simple descriptive statistical methods were used to analyze the data.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The paper also assesses the outcomes of the project against pre-dened Project Development
Objectives, with a focus on providing evidence of project achievements.
The result of RBF in Nigeria have been unprecedented in terms of the improvement to health
outcomes achieved. With the implementation of RBF approach throughout NSHIP, 2,200
primary health facilities across 113 Local Government Areas in eight states have experienced
total transformation and become functional with improved quality service delivery, which has
directly translated to improvements in population health. This has ensured that 30 million
beneciaries including women and children have access to quality basic health care services
and secondary care.
In the Nigerian context, RBF was a timely initiative given the poor health indices at national
and sub-national levels. NSHIP has demonstrated how RBF can serve as an innovative strategy
to increase the impact of investments in health and improve efciency. However, the project
also exposed some gaps in the RBF implementation process, as well as recurrent challenges
deterring it from achieving its full potential. The application of NSHIP has offered valuable
lessons to strengthen the design and application of RBF and inuence national policy.
1, Crédo Ahissou2, Jean Paul Dossou2, Kélath Bello3 and Christelle Boyi4,
(1)Centre de Recherche en Reproduction Humaine et en Démographie, Abomey-Calavi, Benin,
(2)Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin, (3)
Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou,
Benin, (4)centre de Recherche en Reproduction Humaine et en Démographie
In Benin, research addressing Strategic Health Purchasing are almost inexistent. Currently,
several reforms are underway in the country intending to move towards a Strategic Health
Purchasing, although much remains to be done. Consequently, this paper seeks to show the
effort made towards SHP through an assessment of its progress and gaps in Benin.
We combined a cross-sectional qualitative study design with collected data using document
reviews, key informant interviews, and a stakeholder engagement workshop focusing on the
ve main health purchasers in Benin: ANPS: National Agency for Social Protection (for the
health insurance component of the ARCH) project, the ANGC (for the National Free Caesarean
section policy), by the Ministry of Economy and Finance (for the National Pension Fund of
Benin), by the treasury (for the 4/5 scheme for state agents, the Benin National Retirement
Fund), and by insurance companies themselves (for private health insurances and the
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
“Mutuelles de Santé”).
Our results as follow:
The benets specication varies across the health purchasing mechanisms. In the ARCH
project like most of the public schemes for instance, purchasers mostly focus on public
providers whereas the private purchasers tend to contract with private insurance companies.
There is limited autonomy in decision making and nancial management in several schemes
especially those that depend mainly on the government. On the contrary, private insurance
companies and the Mutuelles de santé are autonomous in their decision-making.
Fee-for-service is the most used payment model in most schemes including the ARCH
project. In contrast, the free caesarean section policy and malaria control programs reimburse
providers by paying a lump sum for each caesarean section performed.
Monitoring and evaluation receive little attention in the implementation of most schemes,
mainly due to the lack of information management systems and the fragmentation of existing
information systems. However, in the ARCH project for instance, the monitoring and evaluation
of activities and results are conducted by the same purchasers that do not always provide
objective analyses.
Provider payment methods and contracting policies do not well align with strategic
purchasing in health services comprehensiveness.
Governance is multi-stakeholder in most public regimes. However, there is a low or no real
community participation in decision-making except in the “Mutuelles de santé”. Furthermore,
each SHP scheme has its health information system as a cause of the fragmentation of the
health nancing system.
Chris Atim1, 2 and Daniel Malik Achala1, (1) AfHEA, Accra, Ghana, (2)Kwame
Nkrumah University of Science & Technology (KNUST), Kumasi, Ghana
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The paper examines sustainable health care nancing in Africa. We provide an analysis of the
mix of revenue sources for health including development assistance in Africa using smoothed-
out ve-year averages data from 2000 to 2018. We present a discussion to support the need
to transition to domestic government health expenditure for sustainable nancing. Then
we make projections of economic growth, tax revenues and domestic government health
expenditure taking into account the impacts of the Covid-19 pandemic and suggest alternative
sources of nancing in Africa. We assume domestic health expenditure grows at same rate
as economic growth rates. Further, we assume countries could increase the tax to GDP ratios
to 20%. We use a combination of quantitative and qualitative methods using data from
international databases and repositories of economic and health nancing. We also carried out
a comprehensive desk and literature searches to inform our analysis.
The results indicate a signicant dependence on out-of-pocket and external health
expenditure. Besides, there is low commitment from governments in terms of nancing the
health sector as evident in the inability of most countries to achieve the 15% Abuja target and
the 5% of GDP as health expenditure. Besides, health expenditure per capita is low, falling
below the USD91 recommended for basic health care, coupled with the low levels of both social
and voluntary health insurance in the region. Also using the projected growth rate of GDP and
population, we nd that the pandemic has depressing effects on economic growth rates and
tax revenues in African countries, affecting the ability of the countries to provide sustained
nancing to the health sector. This, therefore, requires effort from countries to mitigate the
impacts of the pandemic in order to improve economic growth rates. Our analysis also shows
that if countries spend at least 5% of GDP as domestic government health expenditure,
countries in Africa can make good progress towards their UHC targets, although there will be
shortfalls as a result of the pandemic hence the need to revise these targets. We also nd that
African countries could mobilize substantial revenues if they increased their tax to GDP ratios
from their current levels to the recommended 20% of GDP as we nd signicant gaps in tax
revenues. We conclude the paper by discussing other innovative sources of nancing that
could improve revenues and hence allocations to the health sector.A
This paper is based on work funded by UNECA &
ABCHealth as part of background analyses for the forthcoming report on Healthcare and
Economic Growth in Africa, 2nd Edition. The authors alone are responsible for the contents
and viewpoints in the paper. Opinions and conclusions in the paper should not be attributed
to UNECA, ABCHealth, or any institution with which the authors are afliated.
Chris Atim1, Eric Arthur2 and 1, (1) AfHEA, Accra, Ghana, (2)Kwame
Nkrumah University of Science & Technology (KNUST), Kumasi, Ghana
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Many African countries have signed onto the sustainable development goals (SDGs). Progress
towards achieving the health related goals has been slow as many countries have low service
coverage. This paper examined the current status of health nancing in Africa and countries’
progress towards universal health coverage (UHC). We analyzed recent macro scal, health
systems and nancing data of African countries. We examined key health systems priorities
including: priority setting and use of technology in health care, strategic purchasing and risk
pooling as well as service coverage. The paper also looked at the impact on countries of the
ongoing Covid-19 pandemic.
A combination of quantitative and qualitative methods were used. Data included international
databases and repositories of economic and health nancing data from World Bank, World
Health Organization (WHO), Primary Healthcare Performance Initiative (PHCPI). The qualitative
aspect made use of comprehensive desk and literature searches of key themes to inform our
analysis.
There is pervasive and very high out-of-pocket (OOP) health spending in Africa. This
presents one of the most signicant challenges to countries’ pursuit of UHC. We found that,
government health expenditure is low in many countries while external health expenditure
even though dwindling, is still high in some countries. With dwindling and unsustainable
external aid and the further impoverishing effects of OOPs, public funding remains the only
viable way for countries to make meaningful progress towards UHC, especially to ensure
that the poor and vulnerable populations obtain the health care they need without facing
any nancial hardship as a result. We further found that strategic purchasing and health
technology assessment, which can boost both allocative and technical efciency in health, are
being underutilized in Africa. Purchasing of health care services in Africa is largely input based
rather than strategic and does not incentivize quality service delivery.
There is still high OOP in many African countries, which is impeding progress to UHC.
Government health spending is key to African countries’ progress towards achieving UHC
given the dwindling and unsustainable external health funds and retrogressive nature of
OOPs. Countries should take advantage of opportunities arising from, among other things,
the response to the Covid-19 pandemic, to maximize the use of strategic purchasing, digital
technology and similar tools to improved health services and outcomes.
This paper is based on work funded by UNECA &
ABCHealth as part of background analyses for the forthcoming report on Healthcare and
Economic Growth in Africa, 2nd Edition. The authors alone are responsible for the contents
and viewpoints in the paper. Opinions and conclusions in the paper should not be attributed
to UNECA, ABCHealth, or any institution with which the authors are afliated.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Felix Houphouet Boigny University of Cocody, Abidjan, Côte d’Ivoire and Rachel
Mukamunana, African Peer Review Mechanism (APRM), South Africa
When an epidemic occurs, the measures taken are generally preventive and may lose their
effectiveness in the long term. Curative solutions are therefore desirable. But these curative
solutions, before being put in place, require several steps that can take years. During this time,
if nothing is done, the epidemic situation could turn into a health crisis, which by impacting
the physical integrity of the population could have a negative effect on economic activity. So
what is the optimum time that should be taken to nd a sustainable solution to epidemics in
order to avoid economic recession?
The aim of this study is to contribute to the understanding of the inuence of the duration
of health crises on economic activity, especially in African countries, where epidemics are
rampant and the Covid-19 crisis is reducing access to antiretrovirals.
The general objective of this paper is to analyse the effect of health crises on economic activity
in Africa. Specically, this study seeks to:
• Identify the nature of the link from health crisis to economic growth;
• Determine the optimal time at which a health crisis can negatively inuence economic
growth.
A linear regression model is applied to a non-linear growth function in the health crisis variable.
The sample of this study concerns a panel of 27 states in Africa, observed over the period 1995-
2017. The generalized method of moments (GMM) was used to estimate the parameters of the
study model.
The results of the study show that health crises in Africa generally have a non-linear effect on
economic growth. When an epidemic starts, immediate response measures tend to develop
certain sectors of activity to the benet of others, leading to a reduction in the economic
growth rate to +0.4%. On the other hand, when these short-term measures persist and are
not transformed into sustainable solutions, a drop in economic growth of around -0.06% is
observed. This decline usually takes place after 3 years 4 months.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
When an epidemic occurs, it is desirable that, in addition to barrier and prevention measures,
the political authorities start to look for sustainable solutions, considering a countdown of 3
years on average.
Joël Arthur Kiendrébéogo², Yamba Kafando¹, Charlemagne Tapsoba³, Issa
Kabore¹, Hamidou Ouédraog, Simon Kabor, Cheickna Tour, and Allison Gamble Kelley6, (1)
Recherche pour la Santé et le Développement (RESADE), Ouagadougou, Burkina Faso, (2)
Université Joseph KI-ZERBO, Department of Public Health, Ouagadougou, Burkina Faso, (3)
Research for Health and Development, Burkina Faso, Burkina Faso, (4)Réseau accès aux
médicaments essentiels (RAME), Ouagadougou, Burkina Faso, (5)Results for Development
(R4D), Kenya, (6)Results for Development (R4D), France
Communities should play a crucial role in the ght against public health emergencies, but
ensuring their effective engagement remains a challenge in many countries. We present the
experience of Burkina Faso in involving community actors in the ght against COVID-19.
To describe the process of mobilising community actors and their contribution to the ght
against COVID-19 in Burkina Faso.
This was a descriptive qualitative study that took place in the city of Ouagadougou, covering
the period from March to October 2020. Data were collected through document review,
individual online interviews and participant observation, and then analysed thematically.
The initiative to involve community actors in the ght against COVID-19 was taken by 23 civil
society organisations grouped around a platform called “Démocratie Sanitaire et Implication
Citoyenne (DES-ICI)”. In April 2020, this platform launched the movement “Communities
are committed to Emptying COVID-19 (COMVID COVID-19)” by mobilising more than 300
community-based associations through social networks. These associations, under the
leadership of the DES-ICI platform, were organised and divided into 54 Citizen Health Watch
Units (CCVS) throughout the city of Ouagadougou. These CCVS worked on a voluntary basis,
carrying out awareness raising activities, identication and follow-up of contact cases. The
CCVS also manufactured and distributed protective materials, including soap, masks and
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
hydro-alcohol gel to vulnerable households. In addition, the COMVID-COVID-19 movement has
helped to initiate dialogue and increased collaboration between civil society and the Ministry
of Health in the response to COVID-19.
The COMVID COVID-19 movement has been essential in the ght against COVID-19 in Burkina
Faso and has been a unique experience in mobilising community actors through civil society.
This movement could inspire other countries, not only in the framework of the response
to COVID-19, but also beyond, for the implementation of community health actions in the
dynamics of the Universal Health Coverage.
, SCHOLL OF PUBLIC HEALTH OF KINSHASA, KINSHASA, Congo-
Kinshasa
User use of health services can decline during epidemics, which was predicted in low- and
middle-income countries during the COVID-19 pandemic. In March 2020, the government of
the Democratic Republic of Congo (DRC) began implementing public health measures across
Kinshasa, including strict containment measures in the Gombe health zone in the capital.
To date, only a small number of studies have assessed the impact of the COVID-19 pandemic
on health service utilisation in LMICs, and none have also assessed both the implementation
and lifting of containment measures. This study therefore falls within this framework.
• To assess the impact of COVID-19 and its associated response measures on health
service utilisation in Kinshasa during the rst wave of the pandemic
• To provide information to guide the response and future infectious disease outbreaks.
Using monthly time series data from the health information system and interrupted time
series data, with segmented Poisson mixed-effects regression models, we assessed the impact
of the pandemic on the use of essential health services during the rst wave of the pandemic
in Kinshasa.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Health service utilisation fell rapidly after the onset of the pandemic and ranged from 16%
for visits for hypertension to 39% for visits for diabetes. However, the reductions were heavily
concentrated in Gombe (81% decrease in outpatient visits) compared to the other health zones.
When the lockdown was lifted, the total number of visits and visits for infectious and non-
communicable diseases increased about twofold. Hospitals were more affected than health
centres. Overall, the use of maternal health services and vaccinations was not signicantly
affected.
The COVID-19 pandemic resulted in signicant reductions in the use of health services in
Kinshasa, particularly in Gombe. The lifting of containment led to a rebound in the level of
health service utilisation, but it remained below pre-pandemic levels.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
.
Chinwe Ogbonna UNFPA, Ama Pokuaa Fenny Institute of Statistical, Social and
Economic Research Howard Friedman,UNFPA, Jocelyn Fenard UNFPA,Nadia Carvalho Avenir
Health Naomi Setshegetso, University of Botswana, Gaborone, Botswana, Jacob Novignon,
Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, Alfred Mukong,
University of Namibia.
In 2019, UNFPA, the United Nations Population Fund estimated the costs and resource gaps
for achieving three transformative results by 2030, namely ending unmet need for family
planning, ending preventable maternal deaths, and ending gender-based violence and
harmful practices. With its collaborating partners, UNFPA launched the Global price tags at the
ICPD25 Nairobi Summit. The global price tags used aggregate country-level estimates for high
burden countries, as guided by tailored tools, a clear methodology and several data sources. To
achieve the three transformative results by 2030 in priority countries, a total cost of $264 billion
was estimated, of which $42 billion was projected as available resources and commitments
in 2019 from donors in the form of development assistance. New investments of $222 billion
were estimated as the nancing gap to meet the three transformative results by 2030. These
resources are expected to be raised from primarily domestic resources, including government
revenue, and innovative nancing sources. It is important to highlight that the global price
tags were estimated in 2019 before the COVID19 pandemic in 2020. There is recognition that
the scale of resources required to close nancing gaps in achieving the Transformative results
could be signicantly greater.
In further recognition of the need for validated country estimates of resource requirements
to achieve the Transformative results and met commitments made by member states at
the Nairobi Summit, Investment cases have gained momentum in Africa. These country-
level investment cases present an opportunity to focus on the unnished business of the
ICPD Agenda at the country level, by dening the scale and scope of investments needed to
prioritize proven, high-impact and cost-effective interventions that are required to accelerate
progress towards achievement of the transformative results committed to by UNFPA and
partners.
Naomi Setshegetso, University of Botswana, Gaborone, Botswana
The family planning programme in Botswana has contributed to improved health outcomes
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and development over the years. This, however, is not without some challenges. One of
the main limitations to scaling up effective coverage of family planning services is limited
availability of disaggregated data on key SRHR indicators to guide targeted interventions.
Botswana relies mainly on programmatic data for tracking progress for the family planning
programme.
Different effective coverage scenarios of the priority interventions were developed in
consultation with the government and partners. The baseline was set as 2020 with projections
to the SDG target year of 2030 for all the coverage projections with the rst year of impact
recorded in 2021. The baseline case (or status quo) scenario assumed that contraceptive
prevalence rate (CPR) of 67.4 percent prevails over time and does not change. Relative to
other scenarios, the baseline case scenario shows how the contraceptive prevalence rate
(and modern CPR) evolves over time relative to the set target in terms of its impact on unmet
need for FP, unintended pregnancies, maternal deaths and unsafe abortions averted. In
the second scenario, it was assumed that the current contraceptive prevalence rate of 67.4
percent only prevails in the base year and thereafter, evolves over time to reach a target of 75
percent in 2030 – a target set by the UN as an SDG for all countries to ensure universal access
to reproductive health care. In the third scenario, it was assumed that current contraceptive
prevalence rate of 67.4 percent increases over time 80 percent by 2030.
The ndings from the estimations show the signicant impact of increasing modern
contraceptive prevalence and addressing unmet need for family planning in terms of
reductions in unintended pregnancies, maternal deaths and unsafe abortions. Specically,
An increase in modern contraceptive prevalence rate from 64.52 percent to 86 percent with
a view to ending unmet need for family planning will increase the scale of impact to avert
unintended pregnancies by 2030.
In total 665,775 unintended pregnancies would be averted between 2020 and 2030 if modern
CPR is 64.52 percent (baseline/status quo with CPR of 67.4 percent).
The public health emergencies and disruptions presented by the COVID-19 pandemic and its
far-reaching impact on lives, livelihoods, and the economy, underscore the need for resilient
health systems, that can ensure continuity of essential services.
Jacob Novignon, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
South Sudan’s maternal mortality rate is relatively high, estimated at 789 maternal deaths per
100,000 live births (UN estimates, 2015). Further, skilled attendance during delivery is at 19%
with 80% of women delivering at home assisted by untrained attendants. The unmet need
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
for contraception in South Sudan was at 29.7% in 2020. Contraceptive prevalence rate for all
methods was estimates at 4% in 2010 and modern methods at 5% as at 2015.
Different effective coverage scenarios of the priority interventions were developed in
consultation with the National Reference Group (NRG). The baseline and end line for all
the coverage projections are 2020 and 2030 respectively and the rst year of impact of the
intervention is 2021. With regards to ending maternal deaths and ending unmet need for
family planning, four different effective coverage scenarios were considered.
Ending preventable maternal deaths:
An achievable (50%) scale up of coverage of twenty-seven (27) high impact maternal health
interventions, including contraceptive use, could save over 5,500 maternal lives over the next
ten years at a total incremental (additional) cost of US$ 318 million in South Sudan or a total
cost of US$ 408 million.
Ending unmet need for family planning:
An increase in the modern contraceptive prevalence rate to 30 to 50%, with a view to ending
unmet need for family planning, will lead to the number of unintended pregnancies averted
increasing from 292,075 in 2020 to between 1,084,243 and 1,717,979 in 2030 under the three
scenarios [Modest (30%), Achievable (40%) and Ambitious (50%)].
Ending Child Marriage:
Over 2 million children (baseline) are likely to be married in the next 10 years if there is no
intervention undertaken. However, with targeted interventions, 62% of child marriages (about
1.4 million) would be averted.
Ending Gender-based violence and all harmful practices:
With a 5% annual increase in the effective coverage of targeted interventions, the number of
women exposed to IPV in South Sudan would start to decline. Between 2021 and 2025, 171,708
cases of IPV would be averted; this approaches half a million by 2030. With a 50% intervention
coverage for all indicators achieved by 2030, 392,376 IPV cumulative incidents would be
averted during the rst 5 years (2021-2025) and nearly 2.3 million incidents averted during the
second half of the decade.
Alfred Mukong, University of Namibia
South Sudan’s maternal mortality rate is relatively high, estimated at 789 maternal deaths per
100,000 live births (UN estimates, 2015). Further, skilled attendance during delivery is at 19%
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
with 80% of women delivering at home assisted by untrained attendants. Family planning
service uptake is extremely low in the country, with an estimated 96% of women aged 15-49
years currently married or in union, unable to use/access any family planning methods; with
only 1% of a total of 4% practicing families having used modern family planning methods. The
unmet need for contraception in South Sudan was at 29.7% in 2020.
Different effective coverage scenarios of the priority interventions were developed in
consultation with the National Reference Group (NRG). The baseline and end line for all
the coverage projections are 2020 and 2030 respectively and the rst year of impact of the
intervention is 2021.
Ending preventable maternal deaths:
An achievable (50%) scale up of coverage of twenty-seven (27) high impact maternal health
interventions, including contraceptive use, could save over 5,500 maternal lives over the next
ten years at a total incremental (additional) cost of US$ 318 million in South Sudan or a total
cost of US$ 408 million.
Ending unmet need for family planning:
An increase in the modern contraceptive prevalence rate to 30 to 50%, with a view to ending
unmet need for family planning, will lead to the number of unintended pregnancies averted
increasing from 292,075 in 2020 to between 1,084,243 and 1,717,979 in 2030 under the three
scenarios [Modest (30%), Achievable (40%) and Ambitious (50%)].
Ending Child Marriage:
Over 2 million children (baseline) are likely to be married in the next 10 years if there is no
intervention undertaken. However, with targeted interventions, 62% of child marriages (about
1.4 million) would be averted.
Ending Gender-based violence and all harmful practices:
With a 5% annual increase in the effective coverage of targeted interventions, the number of
women exposed to IPV in South Sudan would start to decline. Between 2021 and 2025, 171,708
cases of IPV would be averted; this approaches half a million by 2030. With a 50% intervention
coverage for all indicators achieved by 2030, 392,376 IPV cumulative incidents would be
averted during the rst 5 years (2021-2025) and nearly 2.3 million incidents averted during the
second half of the decade.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Martilord Ifechi Ifeanyichi Radboud UMC, Leon Bijlmakers, Department for Health
Evidence, Radboud University Medical Centre, Nijmegen, Netherlands, Juma Adinan, East
Central and Southern Africa Health Community, Arusha, Tanzania, United Republic of, Jakub
Gajewski, Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland,
Henk Broekhuizen, Department of Health and Society, Wageningen University and Research,
Wageningen, Netherlands.
Nine in ten persons in sub-Saharan Africa (SSA) lack access to safe, timely and affordable
surgery. Since the 2015 publication of the Lancet Commission on Global Surgery (LCGS) report,
detailing among others global disparities in access to surgery, there have been national
and regional initiatives to scale up surgery in SSA, including the development and launch of
National, Surgical, Obstetric and Anaesthesia Plans (NSOAPs) in Zambia, Tanzania, Nigeria,
Rwanda and Madagascar. SURG-Africa (Scaling up Safe Surgery for Rural Populations in Africa)
project also trialled a mentorship programme to empower district hospital surgical teams
in Tanzania, Malawi and Zambia to undertake a wider range and a larger number of surgical
procedures at district hospitals. Such efforts are however hampered by limited evidence
on the surgical systems. Exploring different dimensions of the surgical system, this session
will demonstrate the role of economic and systems research in shaping policies for building
resilient surgical systems in SSA.
This session will consist of introductory remarks by the principal organizer/moderator, four
distinct paper presentations, questions and answer sub-session, and concluding remarks. The
rst presentation is a systematic review of literature, assessing and describing the current
situation of nancing of surgery in SSA, and providing policy options for improvements.
The second speaker will present a study into the costs and opportunities for efciency
improvements in delivery of surgeries at regional and district hospitals in Tanzania. The third
presentation will dive deeper into the efciency question by investigating the determinants
of efciency at the district hospitals in Tanzania, Malawi and Zambia, using a mix of Data
Envelopment and regression analyses. The last presentation will employ a systems dynamics
tool – Group Model Building (GMB) workshops – to explore the policy options for implementing
and sustaining district level surgical mentorship model for surgical scale up in Zambia. This will
provide a case study of why and how systems thinking could help in policy formulation and
implementation to minimize policy failures and unintended consequences associated with
complex adaptive systems.
This session will demonstrate that surgery scale-up is possible in SSA but requires
comprehensive, long-term and systems-based policies, starting with the prioritization of
surgery in national resource allocation priorities, and establishment of a dedicated global
surgery fund.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Leon Bijlmakers, Department for Health Evidence, Radboud University Medical Centre,
Nijmegen, Netherlands
This study aimed to provide an overview of current knowledge and situational analysis of
nancing of surgery and anaesthesia across sub-Saharan Africa (SSA).
We performed a scoping review of scientic databases (PubMed, EMBASE, Global Health and
African Index Medicus), grey literature, and websites of development organisations. Screening
and data extraction were conducted by two independent reviewers and abstracted data were
summarized using thematic narrative synthesis per the nancing domains: mobilization,
pooling and purchasing.
The search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132
were related to mobilization, 17 to pooling, and 5 to purchasing. Neglect of surgery in national
health priorities is widespread in SSA and no report was found on national level surgical
expenditures or budgetary allocations. Financial protection mechanisms are weak or non-
existent; poor patients often forego care or face nancial catastrophes in seeking care, even in
the context of universal public nancing (free care) initiatives.
Financing of surgical and anaesthesia care in SSA is as poor as it is under-investigated, calling
for increased national prioritisation and tracking of surgical funding. Improving availability,
accessibility, and affordability of surgical and anaesthesia care require comprehensive and
inclusive policy formulations.
Juma Adinan, East Central and Southern Africa Health Community, Arusha, Tanzania, United
Republic of
This study aimed to calculate and compare the costs of providing surgical care at the district
and regional hospitals; and identify points of possible efciency gains.
Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were
selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
in running the hospitals over a 12 month period were identied and quantied from interviews
and hospital records. Using a combination of step-down costing and activity-based costing, all
costs attributed to surgeries were established and then distributed over the individual types of
surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative
components.
The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet
District Hospital to $3,453k at Mt Meru Regional Referral Hospital. The total costs of surgeries
ranged from $79k to $813k; amounting to 12-22 % of the total costs of running the hospitals.
At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were
generally higher at the district hospitals. Two-thirds of all the procedures incurred at least
60% of their costs in the theatre. Open reduction and internal xation (ORIF) performed at the
regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment)
due to prolonged post-operative inpatient care associated with the latter ($1,177), but was
performed infrequently mostly due to unavailability of implants.
Lower unit costs and shares of capital costs at the RH reect an advantage of economies of
scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater
efciencies make a case for concentration and scale-up of surgical services at the RHs, but
there is a stronger case for scaling up district-level surgeries, not only for equitable access to
services, but also to drive down unit costs there, and free up RH resources for more complex
cases such as ORIF.
Jakub Gajewski, Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin,
Ireland
This paper investigates the determinants of hospital efciency in district hospitals in three
African countries.
Three-months cross-sectional data, comprising surgical capacity indicators and volumes of
major surgical procedures collected from 61 district hospitals in Malawi, Tanzania, and Zambia,
were analysed. Data envelopment analysis was used to calculate average hospital efciency
scores (max.=1) for each country. Quantile regression analysis was selected to estimate the
relationship between surgical volume and input indicators. Two-stage bootstrap regression
analysis was used to estimate the determinants of hospital efciency.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Average hospital efciency scores were 0·77 in Tanzania, 0·70 in Malawi and 0·41 in Zambia.
Infrastructure had the highest weight in calculating these scores. Hospitals that scored high
on the most commonly utilised surgical capacity index were not the ones with high surgical
volumes or high efciency. The number of surgical team members, which was lowest in
Zambia, was strongly, positively correlated with surgical productivity and efciency
Hospital efciency, combining capacity measures and surgical outputs, is a
better indicator of surgical performance than capacity measures, which if used alone for
surgical planning could be misleading. Investment in the surgical workforce is critical to
improving district hospital surgical productivity and efciency.
Henk Broekhuizen, Department of Health and Society, Wageningen University and Research,
Wageningen, Netherlands
The aim of this study was to explore policy options for embedding a pilot surgical mentoring
programme in existing policy structures in Zambia through a participatory modeling
approach.
Four group model building workshops were held, two each at district and central hospitals.
Participants worked in a variety of institutions and had clinical and/or administrative
backgrounds. Two independent reviewers compared the causal loop diagrams (CLDs) that
resulted from these workshops in a pairwise fashion to construct an integrated CLD. Graph
theory was used to analyze the integrated CLD, and dynamic system behavior was explored
using the Method to Analyse Relations between Variables using Enriched Loops (MARVEL)
method.
The establishment of a provincial mentoring faculty, in collaboration with key stakeholders,
would be a necessary step to coordinate and sustain surgical mentoring and to monitor
district-level surgical performance. Quarterly surgical mentoring reviews at the provincial level
are recommended to evaluate and, if needed, adapt mentoring. District hospital administrators
need to closely monitor mentee motivation.
Surgical mentoring can play a key role in scaling up district-level surgery but its
implementation is complex and requires designated provincial level coordination and regular
contact with relevant stakeholders.
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, Economic Community of Central African States (ECCAS), Libreville,
Gabon
Anaclet Ngabonzima1, David, Mark Epstein2, Gisele Mukunde3, Mathias Gakwerere4, Alain
Nyalihama5, David Cechetto3
1Economic Community for Central African States (ECCAS)
2Barcelona School of Management
3Department of Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, University of
Western Ontario, London, Ontario, Canada, N6A 5C1
4UNFPA
5Butare University Teaching Hospital
Prematurity is still the leading cause of neonatal mortality globally, Rwanda included, though
advanced medical technology improved survival for this condition. The initial hospitalization
of premature babies is associated with high costs impacting on the country health budget. In
Rwanda, these costs are not known to allow better related planning, hence the purpose and
motivation for this research.
This is a prospective Cost of Illness study using prevalence approach conducted in 5 hospitals
(Muhima, Masaka, Gisenyi, Ruhengeri and Butare University Teaching Hospital). It includes
premature babies admitted from June to July 2021 followed up till exit prospectively to
determine medical direct costs (MDC) using bottom-up approach. Data was tabulated with
Microsoft Excel and exported into SPSS for additional analysis. The overall and other different
mean MDC were determined. The country MDC was estimated based on recent incidence.
Linear relationship between explanatory and outcome variable was assessed and cost
prediction done using Linear Regression model. The signicance level was set at p <0.05.
A total of 123 preterm babies were recruited. Very preterm and moderate preterm babies were
36.6% and 23.6% respectively. The overall mean MDC was 237.72 $ (SD 294.97 $) and the cost
per infant varied with prematurity degree, weight category, hospital level and length of stay.
MDC were dominated by drugs and supplies (65%) and oxygen was the cost driver of MDC
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
accounting itself 38.40% of total costs. Birth weight (BW) was the most powerful predictive
factor for both hospital stay and MDC and served for predictions.
Analysis and prediction of MDC in this study provide in-depth understanding of BW as cost
predictive factor to be tackled through measures to prevent or delay preterm birth. The oxygen
related cost accounts for high proportion of MDC and this cost may be reduced by placing
oxygen plants across hospitals.
Colin Gilmartin, Management Sciences for Health, Philadelphia, PA, Justice Nonvignon,
Department of Health Policy, Planning and Management, School of Public Health, University
of Ghana, Legon, Ghana, , Benin National Malaria Control
Program, Benin, Patrick Makoutode, CERRHUD, Benin, Amanda Schulhofer, Johns Hopkins
University and Zana Somda, Management Sciences for Health
Seasonal malaria chemoprevention (SMC) – the intermittent administration of sulfadoxine-
pyrimethamine plus amodiaquine during peak malaria transmission months – is
recommended for children aged 3–59 months living in eligible geographic areas to prevent
Plasmodium falciparum. Although SMC is considered a low-cost and highly cost-effective
intervention, there is a need to understand the cost-effectiveness of different administration
strategies to inform future planning and resource allocation. The objective of this study is
to assess the cost-effectiveness of two methods of monthly SMC administration in northern
Benin, comparing three-days of directly observed treatment (3-day DOT) by a trained provider
versus one-day of directly observed treatment (1-day DOT) by a trained provider with the
subsequent two doses provided by the child’s caregiver.
We conducted a cost-effectiveness analysis of the 2020 SMC campaign which targeted
four health zones – Tanguiéta Matéri Cobly (TMC), Malanville Karimama (MK), Banikoara
(BNK), and Kandi Gogounou Ségbana (KGS) – targeting 304,772 children aged 3-59 months.
Zones BNK and KGS utilized the 3-day DOT strategy and zones TMC and MK utilized the
one-day DOT strategy. The nancial and economic costs were captured from expenditure
reports, microplans, and in-person interviews and were analyzed from both the program
and household perspectives. The main effects measures were malaria cases, deaths, and
disability-adjusted life-years (DALYs) averted which were estimated from reported numbers
of SMC treatments administered and modelled effects using a decision analytic model which
incorporated data on SMC effectiveness and malaria transmission which were obtained from
the literature. One-way sensitivity analyses were conducted to test the robustness of the
incremental cost-effectiveness ratio (ICER).
The total cost of the 2020 SMC campaign was $1.6 million (FCFA 879 million) in the 1-day DOT
zones and $2 million (FCFA 1 billion) in the 3-day DOT zones. The cost per monthly SMC cycle
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
delivered to a child was $3.71 (FCFA 1,983) in the 1-day DOT zones compared with $3.13 (FCFA
1,673) in the 3-day DOT zones. The 3-day DOT strategy was the most cost-effective across all
effects outcomes with an incremental cost-effectiveness ratio (ICER) of $446 (FCFA 238,409)
per discounted DALY averted. One-way deterministic sensitivity analyses demonstrated that
even under the most conservative estimates, the ICER remained cost-effective.
Both 1-DOT and 3-DOT are low cost and cost-effective strategies for SMC administration, with
the 3-day DOT administration considered more cost-effective. This evidence should help in
guiding future program planning and resource allocation for SMC in Benin and other SMC-
eligible countries.
1, Vincent Were2, Lynda Isaaka2, Ambrose Agweyu2, Samuel Aketch2 and Edwine
Barasa1, (1)Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme,
Nairobi, Kenya, (2)KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
Case management of symptomatic COVID-19 patients is a key health system intervention. The
Kenyan government embarked to ll capacity gaps in essential and advanced critical care
needed for the management of severe and critical COVID-19. However, given scarce resources,
gaps in both essential and advanced critical care persist. This study assessed the cost-
effectiveness of investments in essential and advanced critical care to inform the prioritization
of investment decisions.
We employed a decision tree model to assess the incremental cost-effectiveness of investment
in essential care (EC) and investment in both essential and advanced critical care (EC+ACC)
compared to current health care provision capacity (status quo) for COVID-19 patients in
Kenya. We used a health system perspective, and an inpatient care episode time horizon. Cost
data was obtained from primary empirical analysis while outcomes data was obtained from
epidemiological model estimates. We used univariate and probabilistic sensitivity analysis
(PSA) to assess the robustness of the results.
The status quo option is more costly and less effective compared to investment in essential
care and is thus dominated by the later. The incremental cost effectiveness ratio (ICER)
of Investment in essential and advanced critical care (EC+ACC) was US $1,378.21 per DALY
averted and hence not a cost-effective strategy when compared to Kenya’s cost-effectiveness
threshold (USD 908).
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
When the criterion of cost-effectiveness is considered, and within the context of resource
scarcity, Kenya will achieve better value for money if it prioritizes investments in essential
care before investments in advanced critical care. This information on cost-effectiveness will
however need to be considered as part of a multi-criteria decision-making framework that
uses a range of criteria that reect societal values of the Kenyan society.
COVID-19, cost-effectiveness, essential care, advanced critical care, Kenya
, Ministry of Health Ethiopia, Addis Ababa, Ethiopia, Michael Tekle
Palm, Clinton Health Access Initiative, Addis Ababa, Ethiopia, Ethiopia, Stephane Verguet,
Harvard T.H. Chan School of Public Health, Boston, MA, USA, WA, Solomon Tessema Memirie,
Department of Pediatrics and Child Health, College of Health Sciences, Addis Ababa
University, Addis Ababa, Ethiopia, Ethiopia, Mieraf Taddesse Tolla, Department of Global
Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting (BCEPS),
University of Bergen, Bergen, Norway, Norway and Ole F Norheim, Department of Global
Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting (BCEPS)
Despite the recently increasing global initiatives for childhood cancer, most recommended
interventions to improve survival and quality of life of children with cancers in Low Income
Countries (LICs) are classied as either low or medium priority in the recently revised Ethiopia
Essential Health Service Package (EEHSP), due to the limitation of local evidence on cost and
cost-effectiveness.
We collected historical cost data and quantity of service provided for the pediatric oncology
unit, and all other (eighty-six) departments in Tikur Anbessa Specialized Hospital (TASH) from
8 July 2018 to June 2019, using mixed (dominantly top down) costing approach and provider
perspective. The direct cost (Human Resource, Drug and Supplies, Medical Equipment) of
the oncology unit, cost share from other clinical departments, and overhead cost share are
summed up to estimate the total annual cost of running the unit. We used data on health
outcome from other studies to estimate the net utility gain (DALY averted) of running a
pediatric oncology unit compared to doing-nothing scenario. We applied the WHO-CHOICE
threshold to determine willingness-to-pay for Ethiopia.
The annual total cost of running the pediatric oncology unit in TASH during 2018-2019 was USD
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
797,458 (USD 482 per patient). Drugs and supplies (33%), and personnel (32%) constitute a large
share of the cost. Sixty two percent of the cost is attributable to Inpatient Department (IPD)
services, with the remaining 38% of costs related to Outpatient Department (OPD) services.
The cost per DALY averted is USD 726 (range USD 555 to USD 905 on the one-way sensitivity
analysis) which lies below the threshold for “very cost effective” interventions, which is set as
the 2019 Ethiopian GDP per capita (USD 954/capita).
The provision of pediatric cancer services using a specialized oncology unit is very cost effective
in Ethiopia and will most likely be the case in other LICs. We recommend for reassessing the
Childhood cancer treatment priority level decision in the current EHSPE.
1, Rouden Mkisi2, Vincent Masoo3, Chisema Nenani4, Dennis
Mwagomba4, Mpatso Mtenje4, Dr. Fumbani Limani, MBBS, MMed Internal Medicine5 and Clint
Pecenka6, (1)PATH, Geneva, Switzerland, (2)PATH, Malawi, (3)Mzuzu central Hospital, Malawi,
(4)Expanded Program on Immunization, Ministry of Health, Malawi, (5)Malawi Liverpool
Wellcome Trust, Blantyre, Malawi, (6)PATH
In 2018 the World Health Organization formally recommended the introduction of typhoid
conjugate vaccine (TCV) in typhoid-endemic settings. Despite a substantial typhoid burden in
sub-Saharan Africa, TCV has only been introduced in two African countries. Decision-makers in
Malawi decided to introduce TCV and applied to Gavi, the Vaccine Alliance, in September 2020.
The current plan is to introduce TCV as part of the national immunization program in October
2022. The introduction will include a nationwide campaign targeting all children aged 9-month
to 15 years old. Following the campaign, TCV will be provided through routine immunization at
9 months. This study aims to estimate the cost of TCV introduction and delivery, based on the
delivery strategies dened in Malawi’s National Plan of Action.
This costing analysis is conducted from the perspective of the government and focuses on
projecting the incremental cost of TCV introduction. The study will take an activity-based,
ingredients costing approach, where all activities associated with the introduction and
delivery of the vaccine are identied, measured, and valued individually, reporting separate
quantities and unit prices. Both nancial and economic costs are included in the analysis. The
study uses a costing tool developed by Levin and Morgan through a partnership between the
International Vaccine Institute and the World Health Organization. Primary and secondary
data have been collected through key informant interviews with representatives of the Malawi
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Expanded Program on Immunization team at central level as well as in 4 districts and a total of
24 local health facilities. Primary data in health facilities were collected through interviews with
health workers involved in immunization activities using costing questionnaires.
will include total nancial and economic costs of TCV introduction in Malawi, plus
service delivery cost per dose via the campaign and in routine immunization. Costs will be
reported by main activities (training, microplanning, supervision, etc.), and cost categories
(introduction costs and recurrent costs), highlighting major cost drivers.
Findings from this analysis (expected by Novermber 2021) will be critical in assessing the
economic implications of delivering TCV, and in informing decision-making and budget
planning in anticipation of TCV introduction in Malawi. Major cost drivers highlighted by the
analysis may also inform decision-makers from other countries in the region as they assess
value and feasibility to introduce TCV in their national immunization program.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Maduka Ughasoro1, James Akpeh2, 2, Somkene Okpala2 and
Nneka Mgbachi3, (1)University of Nigeria Enugu Campus, Enugu, Nigeria, (2)University of
Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Enugu, Nigeria, (3)University of Nigeria
Teaching Hospital, Ituku-Ozalla, Enugu., Enugu, Nigeria
Acute tonsillitis has become one of the main reasons why children visit healthcare facilities in
Nigeria. Presently, there is no information on the costs of its treatment, and this study aimed at
determining these costs.
The study was conducted in two hospitals located in the southeast of Nigeria. The information
was obtained in two ways: (1) retrospectively from the medical records of children treated for
acute tonsillitis over a period of 5 years and (2) cross-sectionally from children who presented
with complaints of acute tonsillitis over a period of 7 months. The information obtained was
the costs of self-medication, hospital treatment, and the payment mechanisms used to settle
these costs. The human capital method approach was used to estimate the indirect cost (loss
in productivity) from the caregivers’ absenteeism from work.
The mean costs of self-medication and hospital treatment for acute tonsillitis in children were
€3.85 and €13.48, respectively. The indirect cost was €11.31. The mean total cost of treatment
of acute tonsillitis was €23.80. The proportion of households that suffered catastrophic health
expenditure (CHE) from the treatment of acute tonsillitis was 55 (55%). CHE was highest [22
(91.7%)] in the lowest socio-economic quartile compared to households in the highest quartile
[4 (16.7%)], and the difference was statistically signicant (p = 0.02). Of the 72 participants
whose
payment mechanisms were documented, the proportion who paid out of pocket was 53
(73.6%), and 19 (26.4%) used the National Health Insurance Scheme.
The costs of treatment for children with acute tonsillitis were high, and most of these costs
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
were settled out-of-pocket. The costs for laboratory investigations, drugs, and productivity loss
contributed to these high costs. There is a need to cover the costs of non-surgical treatment of
acute tonsillitis in social health insurance and improve efforts to increase the coverage of the
health insurance scheme.
Chinwe Weli1, Tamilore Areola1, Kelechi Ohiri1, Yewande Ogundeji2 and 3, (1)
Health Strategy and Delivery Foundation, (2)Health Strategy and Delivery Foundation, FCT,
Canada, (3)HSDF, Nigeria, Nigeria
Nigeria is experiencing demographic and disease transitions, which have results in a rise in
non- communicable diseases (NCDs) such as diabetes mellitus (DM), hypertension (HTN),
cancer and injuries. There are no recent granular costs of providing these services at the
primary healthcare level, which are needed to inform policy makers and nancial planning.
To help address these complex set of challenges, we conducted a costing study to explore the
preparedness of Nigeria to nance the changing health and resource needs associated with
these health transitions.
Primary data were collected from 24 health facilities in four states in Nigeria (Kaduna, Lagos,
FCT and Imo). A combined costing approach which involved both top-down (allocation) and
bottom-up (ingredients-based) methods was used to determine the unit costs associated with
the service delivery of HTN, DM and injury interventions.
Overall, the estimated total unit cost for facilities to provide hypertension and diabetes
mellitus treatment services to a single patient is 51,805 NGN (US $144) and 154,636 NGN (US
$430) respectively. Further, the estimated total unit cost for facilities to provide injury services
is 280,654 NGN (US $780). Drug costs are the major variable cost drivers for hypertension,
diabetes mellitus, and injuries at 11,655 NGN (US $32), 36,784 NGN (US $102) and 122,976 NGN
(US $342) respectively.
NCDs, injuries and accidents services incur high service costs which can lead to high out-of-
pocket expenses. The study estimates can be used for necessary planning and policy solutions
to effectively and sustainably offer a wider scope of essential benet package of services to the
Nigerian population.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Angela Kairu1, Anthony Ngatia2, John Ojal3 and Edwine Barasa1, (1)Health
Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,
(2)Clinton Health Access Initiative, Nairobi, Kenya, (3)KEMRI-Wellcome Trust Research
Programme, Kili, Kenya
COVID-19 vaccines are considered the path out of the pandemic. As a result, the government
of Kenya deployed the COVID-19 vaccine in March 2021 in a phased approach. This study aimed
to estimate the nancial and economic incremental costs of procuring and delivering the
COVID-19 vaccine in Kenya across various vaccination strategies.
We used an activity-based costing approach to estimate the incremental costs of COVID-19
vaccine delivery, from the provider’s perspective. Document reviews and key informant
interviews with stakeholders involved in the vaccine delivery and administration at a national
level and in two counties were done to inform the activities and assumptions used in the
analysis, as well as the resources required. Unit prices were derived from the same document
reviews or from market prices. Both nancial and economic vaccine procurement costs per
person vaccinated with two doses, and the vaccine delivery costs per person vaccinated with
two doses were estimated and reported in 2021 USD.
The economic costs of vaccine procurement per person vaccinated with two doses was $17.34.
The nancial costs of vaccine delivery per person vaccinated with two doses ranged from $4.23
to $3.25 in the 30% and 100% coverage strategies. Estimates of the economic delivery costs per
person vaccinated with two doses were between two and three times higher than the nancial
costs. With the exception of procurement costs, the main cost driver of nancial and economic
delivery costs were supply chain activities (47-59% of total nancial costs) and advocacy,
communication and social mobilization activities (29-35% of total economic costs) respectively.
This analysis presents cost estimates that can be used to inform local policy and may further
inform parameters used in cost-effectiveness models. The results although less generalizable
to other similar low-and middle-income settings in the current format, could potentially be
adapted and adjusted to country-specic assumptions. Therefore, adding to the evidence
available on COVID-19 vaccine delivery costs.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Mahamoudou Touré2, Oumar Sangho2, Hannah Marker3, Birama Djan Diakité4,
Hamadoun Sangho2, Peter Winch3, Seydou Doumbia2, Joshua Yukich5 and Mark McGovern6,
(1)National Institute of Public Health (INSP) and University of Sciences, Techniques and
Technologies of Bamako (USTTB), Bamako, Mali, (2)University of Sciences, Techniques and
Technologies of Bamako (USTTB), Bamako, Mali, (3)Bloomberg School of Public Health, Johns
Hopkins University, Baltimore, MD, (4)National Institute of Public Health (INSP), Bamako,
Mali, (5)Tulane University, New Orleans, United-States, (6)Department of Biostatistics and
Epidemiology, Rutgers School of Public Health, Piscataway
Malaria prevention in children under 5 years of age relies mainly on two strategies: the use of
long-lasting insecticide-treated nets and indoor residual spraying. These strategies are usually
combined with intermittent preventive treatment called seasonal malaria chemoprevention
(SMC) with sulfadoxine-pyrimethamine and amodiaquine (SPAQ). Increasing resistance to
SPAQ has led some countries, including Mali, to experiment with other treatments, including
dihydroartemisinin-piperaquine (DHAPQ). The objective of this study was to evaluate the cost-
effectiveness of the two treatments for SMC and their extension to children aged 5 to 10 years.
This is a four-round quasi-experimental trial with three treatment arms, each composed of
three health areas (villages) in the Koulikoro health district: control arm using standard SMC
treatment for children aged 0-4 years; treatment arm using standard treatment for children
aged 0-9 years; and another treatment arm using DHAPQ for children aged 0-9 years. Data
were collected monthly between July and October in 2020 on 6,326 children. Costs were
estimated from the provider’s perspective; we calculated the total cost and the cost per child
who received treatment. Using the decision tree model, we attempted to estimate the cost-
effectiveness ratio and the incremental cost-effectiveness ratio to determine the most cost-
effective strategy. A sensitivity analysis is also performed to examine the sensitivity of the
results to our assumptions about data quality and price differences.
Our initial results show a low prevalence of malaria among children in both SMC extension
arms compared to the control arm. Extension appears to be benecial in reducing malaria
prevalence in children aged 0-4 years.
Our initial results show a benet of extending SMC to older children regardless of treatment
type. Ongoing unit cost and cost-effectiveness analyses will help determine the value of
committing additional resources to SMC for expansion to children aged 5-9 years.
Cost, cost-effectiveness, Decision Tree Model, Seasonal Malaria Chemoprevention,
SMC, Child, Mali
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Jacob Kazungu1, 2, Kalin Werner3, Nicholas Risko4, Andres Vecino-Ortiz4
and Vincent Were5, (1)Health Economics Research Unit, KEMRI-Wellcome Trust Research
Programme, Nairobi, Kenya, (2)World Bank Kenya, (3)University of Cape Town, Cape Town,
South Africa, (4)Johns Hopkins University School of Medicine, Baltimore, MD, United States of
America, (5)KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
Healthcare workers are at a higher risk of COVID-19 infection during care encounters compared
to the general population. Personal Protective Equipment (PPE) have been shown to protect
COVID-19 among healthcare workers, however, Kenya has faced PPE shortages that can
adequately protect all healthcare workers. We, therefore, examined the health and economic
consequences of investing in PPE for healthcare workers in Kenya.
We conducted a cost-effectiveness and return on investment (ROI) analysis using a decision-
analytic model following the Consolidated Health Economic Evaluation Reporting Standards
(CHEERS) guidelines. We examined two outcomes: 1) the incremental cost per healthcare
worker death averted, and 2) the incremental cost per healthcare worker COVID-19 case
averted. We performed a multivariate sensitivity analysis using 10,000 Monte Carlo simulations.
Kenya would need to invest $3.12 million (95% CI: 2.65–3.59) to adequately protect healthcare
workers against COVID-19. This investment would avert 416 (IQR: 330–517) and 30,041 (IQR:
7243 – 102,480) healthcare worker deaths and COVID-19 cases respectively. Additionally, such
an investment would result in a healthcare system ROI of $170.64 million (IQR: 138–209) –
equivalent to an 11.04 times return.
Despite other nationwide COVID-19 prevention measures such as social distancing, over 70% of
healthcare workers will still be infected if the availability of PPE remains scarce. As part of the
COVID-19 response strategy, the government should consider adequate investment in PPE for
all healthcare workers in the country as it provides a large return on investment and it is value
for money.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Benjamin Chudi Uzochukwu2 and Udochukwu Ogu1, (1)HPRG,
Enugu, Nigeria, (2)University of Nigeria Enugu Campus, Enugu, Nigeria
Developing leadership competencies in the Nigerian Health sector has become a dire need.
Thus it is imperative to ensure that strategic leaders being trained, receive the most suitable
training that will enable them to effectively turn knowledge into practice and take decisions
that can make health more resilient to pandemics.
The study adopted a descriptive, cross-sectional design. A qualitative method of data collection
was used. There were three categories of respondents and three unique in-depth interview
guides (one for each category of respondents). A total of 21 respondents were interviewed.
These respondents comprised of 12 policymakers, 6 tutors (lecturers) and 3 prospective
students of DrPH. They were all purposively selected to t the desired categories for the study.
In addition, 21 published literatures in relation to the study objectives were reviewed by the
researchers and relevant information extracted.
The ndings report that the wider environment where strategic leaders work is not conducive
and has led to lack of satisfaction, motivation, shortage of manpower and the needed political
will to drive health decisions, especially in the face of pandemics. Also, among the core
competencies needed in order to be a strategic leader are critical thinking and analysis, team
work, advocacy, analysis and communication etc. The training curriculum for strategic leaders
should be designed to impact competency to solve identied problems at the end of the
training and also to identify strategies that can make the health sector more resilient to future
pandemics.
In order to ensure that those who are being trained to be the next generation of leaders for
any health institution are equipped to move the said institution forward, a sort of agreement
has to exist between trainers and trainees, ensuring that the trainee will provide services for
a stipulated period. They must be given resources to work with and an enabling environment
has to be created, amongst other things, to enable them deliver their mission. While the
trainees have to be focused on ways that can strengthen the building blocks and in turn,
strengthen the health systems of their institutions, to impact the sub-national and national
levels respectively.
Strategic leadership, Leadership training, Training needs, Health leadership, Nigeria
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, NCDC, Nigeria
Disease surveillance and response improves the ow of surveillance information to monitor
the spread of disease, evaluates the effectiveness of control and preventive measures.
Integrated Disease Surveillance and Response (IDSR) tool and Surveillance Outbreak Response
Management and Analysis System (SORMAS) captures all the surveillance data on COVID-19
and other Vaccine prevented Diseases (VPD) in Nigeria. Having a robust database is not
enough but data must be analyzed and transform into evidence informed decision making.
The aim of this study is to improve the knowledge and capacity of surveillance actors to access
and utilize relevant evidence via ICT training. It also measures the usefulness of training to
enhance the capacity of the participants to develop evidence inform decision making on
COVID-19 response.
A modied “before and after” intervention study design was used in which outcomes were
measured on the target participants. A 5-point liker scale according to the degree of adequacy;
1 = grossly inadequate, 5 = very adequate was employed. The difference between the before
and after measurements was taken to be the impact of the intervention. This study was
conducted in Anambra State, south-eastern Nigeria and the participants were Surveillance
Actors. A one-day intensive training workshop was organized for Surveillance Actors who had
32 participants in attendance. Topics covered included: (i). Active Case Search; (ii). Event-Based
Surveillance; (iii) Use of ICT for evidence synthesis; (iv) Measures of Central Tendency.
The pre-training mean of knowledge and capacity for use of ICT ranged from 2.44-3.25, while
the post-training mean ranged from 3.75-4.00 on 5-point scale. The percentage increase in
mean of knowledge and capacity at the end is 20%.
of this study suggests that ICT competence relevant to translating data to evidence
informed decision making can be enhanced through training workshop.
Evidence-Informed, Decision making, surveillance actors SORMAS, Data
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Regional Institute for Population Studies, University of Ghana, Legon;
Citadel Research Network for Development, Mampong-Ashanti, Accra, Ghana
Despite the present global and national drive to give priority to population ageing, achieving
universal health coverage would continue to remain an unfullled agenda without focusing
on quality healthcare services for all, particularly, older persons. The characterization of
population ageing is associated with increasing disease prevalence and disability. It is against
this backdrop that several social intervention programmes like national health insurance and
cash transfers have been introduced to promote access and utilization of healthcare in Ghana.
This, in turn, may not only strengthen Ghana’s healthcare systems in achieving UHC unless it is
linked to quality essential services to its progressively ageing population.
Guided by the Donabedian’ quality of care model, this paper provides insights into the
expectations of older persons in accessing quality healthcare, and the associated factors in
eight cash grant-selected communities in Ghana.
Data were extracted from the Ageing, Social Protection and Health Systems (ASPHS) survey
carried out between September 2017 and October 2017 among older persons (60+ years)
residing in cash transfer-targeted communities. The study sought to explore information on
the quality of care expectations using the modied version of the “QUOTE-Elderly instrument”
with 32 items. Statistical techniques used for data analysis were descriptive, multivariate
analysis (exploratory factor analysis), and the multiple logistic regression models using Stata
14.1 software.
The mean age was 73.7years. More than half were females and rural dwellers respectively.
One-third had no formal education. Two-thirds were engaged in agriculture. One-fth had no
form of caregiving. 77.2% reported having NCDs. Sixty percent were NHIS enrollees. Fifty-nine
percent achieved insurance membership as Exempt by age, indigent or as a beneciary of
the Cash grant program. With an overall Cronbach’s coefcient of 0.96, communication and
respect, adequate service delivery, provider attitude, cost and geographic accessibility were the
ve main sub-scales found to be extremely important in accessing quality healthcare among
older persons. Though health insurance status was found to have some signicant level
associated with provider attitude and geographic access, household food security, having a
primary caregiver, wealth index, rurality and health status were predictors associated with the
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
different dimensions of quality of care.
Understanding the diverse expectations of the dimensions of quality of care, and their related
factors among older persons is key in ensuring universal health coverage as a guarantee in
building strong health systems for older persons, particularly in this pandemic era.
1, Sakshi Mohan2, Finn McGuire3, Simon Walker4, Peter C. Smith5, Gerald Manthalu6,
Chrispus Mayora7 and Freddie Ssengooba7, (1)Centre for Health Economics, University of
York, York, United Kingdom, (2)Center for Health Economics, University of York, York, United
Kingdom, (3)University of York, Addis Ababa, Ethiopia, (4)University of York, United Kingdom,
(5)University of York, York, United Kingdom, (6)Ministry of Health, Lilongwe, Malawi, (7)School
of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
A well-functioning healthcare system is essential to enable the delivery of clinical and public
health interventions that can improve population health. However, it has proved challenging to
determine the value of investments in health systems strengthening (HSS) compared to more
direct funding of interventions that have a proximate impact on individual health. Economic
evaluation to guide resource allocation has overwhelmingly focused on clinical interventions
and has neglected issues of guiding resources towards HSS.
We conducted a short review of the state of the literature to examine how assessments of
the value of HSS have been considered to date, drawing distinction between theoretical and
empirical contributions. We then assess the existing literature on how the value of HSS can
be assessed and summarise and present empirical estimates on the impact of specic health
system investments. The most promising directions for future health economic research to
guide resource allocation towards HSS are presented.
Providing evidence on the value of HSS is very challenging because its benets cut
across several health-related activities and are mediated through many different types of
interventions. In recent years, theoretical literature has provided greater insight into how
the value of HSS can be determined, but this has not yet translated to a stronger empirical
evidence base. Results from two new studies could offer a model for further research and
to guide future investments in HSS. In Uganda, it is found that investing budgets to expand
availability of certain cadres of healthcare workers could result in more than 15 times the
health impact of an equivalent additional spend on priority drugs and commodities In Malawi,
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
a 25% increase in feasible coverage levels through HSS would have a similar health impact to
eliminating some of the leading infectious diseases. We outline how this literature could be
further developed and highlight 4 approaches that hold most promise.
HSS is likely to have a sizeable benecial impact on population health, potential much more
than expanding budgets for drugs and commodities. In future, a richer empirical literature is
possible that would build upon the most promising recent theoretical contributions.
1, Sally A Sa2, Yentema Onadja3, Roch Millogo3, Linnea Zimmerman1,
Shreena Malaviya1, David Bishai1 and Logan Brenzel4, (1)Johns Hopkins Bloomberg School
of Public Health, (2)Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, (3)
Université Joseph Ki-Zerbo, (4)Bill & Melinda Gates Foundation
Economic principles can guide efcient and equitable allocation of healthcare resources.
In low and middle-income countries, where resources are particularly scarce, expertise in
applied health economics is limited. To address this critical gap in capacity, Teaching Vaccine
Economics Everywhere (TVEE), in partnership with faculty from Johns Hopkins University
and Institut Supérieur des Sciences de la Population (ISSP) of Joseph Ki-Zerbo University of
Ouagadougou, conducted a virtual Training of Trainers (TOT) in Health Economic Evaluation
during July 19-23, 2021.
To assess self-reported knowledge gain and readiness to teach health economic evaluation for
public health decision-making among participants of the TVEE TOT.
We analyzed responses to a post-training survey administered to n=16 respondents who
attended the virtual TOT. The TOT, conducted in French, was designed to equip teaching
faculty at universities and training institutes in West Africa to deliver university-level training in
economic evaluation for public health decision-making. Topics covered included an overview
of the concept of value in public health and methods and practical considerations of economic
evaluation. The survey included 18 questions, which asked respondents to rate their knowledge
of health economic evaluation concepts before and after the TOT and to evaluate the training
they received.
TOT participants represented ve countries including Burkina Faso (9), Senegal (2), Mali
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
(2), Cote d’Ivoire (2), and Cameroon (1). Twelve (75%) participants rated their knowledge of
economic evaluation for public health decision-making as beginner (n=7) or intermediate
(n=5) prior to the TOT; this share declined to 31% (n=5) after the TOT. The share of participants
reporting a mastery knowledge level increased from 6% (n=1) before to 19% (n=3) after the TOT.
Participants also expressed appreciation for the training, reporting a mean rating of 4.3 out
of 5 of the training overall (range, 4-5) and an average rating of 3.8 out of 5 (range, 3-5) of their
readiness to integrate, adapt and deliver courses in economic evaluation for public health
decision making. All 16 participants reported plans to integrate the curriculum into a course
they teach.
These results suggest that low-cost, virtually-delivered, high-quality capacity-building
programs, such as the one offered by TVEE, have the potential to increase trainers’ knowledge
and readiness to teach topics in health economic evaluation for public health decision-making
in low-resource settings. Our group plans to conduct follow up surveys to monitor whether and
how TOT participants integrate the TVEE curriculum into their courses.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Nkoli Uguru1, 2, Joshansen Dioka1 and Chibuzo Uguru1, (1)University of Nigeria,
Enugu, Nigeria, (2)University of Abuja, Abuja, Nigeria
The COVID-19 outbreak has impacted on health care system globally and has resulted in many
emergency measures taken by governing countries. The lockdown, lack of adequate Personal
Protective Equipment (PPE) and safety measures at health care facilities, have resulted in
closure of regular outpatient services leading to substantial decrease in patient turnover at
dental departments. This study was carried out to determine the impact of COVID-19 on the
utilization of dental services amongst University of Nigeria Enugu Campus students.
A descriptive quantitative survey, which was conducted among 422 students of University
of Nigeria, Enugu Campus in November 2020. A multistage sampling technique was used
to select sample and the sample size was calculated using Fisher’s formula for minimum
sample size estimation for a denite population (n = Z2 p (1-p)/ d2). Data was collected using a
structured interviewer administered questionnaire. The data generated were analyzed using
SPSS 25.0
Majority of the respondents (71.3%) had good knowledge of COVID-19. The respondents (83.3%)
stated that the pandemic was found to signicantly affect dental service utilization as there
was a drastic decrease in the number of students who visited the dentist during the pandemic
(from 40.4% to 9.6%) (0.05). The major reason for the poor utilization of dental services among
the students was the fear of contracting the virus (80%) (0.05). To improve dental service
utilization, observation of safety precautions, health education and awareness creation is
integral.
The COVID-19 pandemic has had a profound impact on the health care system, including the
dental industry. To improve dental service utilization in the post pandemic period, dentists
should be prepared to improve on infection prevention protocols and also assist patients
in understanding and prioritizing their dental health needs, which may change in the post
pandemic era. Thus awareness building and increased oral health prevention and control
measures are required.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Samuel Mpinganjira2, Vincent Samuel2, Mercy Malopa2, Dalitso
Longwe2, Tonny Nyirenda2 and Victor Mwapasa2, (1)Kamuzu University of Health Sciences,
School of Public Health,Department of Health Systems and Policy, (2)Kamuzu University of
Health Sciences, School of Public Health, Department of Public Health, Blantyre, Malawi
To reduce local transmission of COVID-19 infections, many countries have adopted the
World Health Organization measures such as self-isolation of conrmed COVID-19 cases and
quarantine of suspected cases. However, little information exists on the economic impact of
such COVID-19 measures in low-income countries where most people work in the informal
sector and can hardly work from home. The objective of this study was to assess the socio-
economic burden of COVID-19 at household level.
From December 2020 to September 2021, we conducted a cross-sectional descriptive study
in urban and peri-urban areas of Blantyre. A structured questionnaire was administered to
individuals with conrmed COVID-19 and/or their guardians within 14 days after COVID-19
diagnosis. Data on socio-demographics, care seeking behaviours, costs associated with
care and labour force participation including consequences related to COVID-19 illness were
collected.
A total of 574 individuals took part in the study, including 169 (29.4%) COVID-19 cases of whom
16% had pre-existing illnesses. Cases had a mean age of 40.7 years, 73.3% were married, 61.3%
attained tertiary education and 55.9% were formally employed. Only 2% of un-employed cases
reported to have lost a job in the 6 months preceding the study. About 65.7% of COVID-19
cases sought formal treatment, 8.3% received in-patient care, spending an average of 3.1 days
in hospitals. Average household expenditures on healthcare were MK6,125, MK62,500 and
MK501,000 for transport, diagnosis and treatment, respectively. (1 USD=MK980). Of the 16%
cases with pre-existing chronic illnesses, 15% reported interruption of access to care for their
illnesses. Of these, 25, 50 and 25 % reported severe, moderate and minor disruptions to routine
healthcare, respectively.
Approximately 15% of households reported a change in consumption, of these 18% borrowed
money, 11% sold asserts and 7% delayed bill-payments as coping mechanism. Majority of the
households (81.4%) expressed the need for direct nancial support whereas 11.5% reported
need for food and medical support.
COVID-19 infection was associated with moderate short-term negative consequences among
households characterized by reduced consumption and disruptions in health care utilization
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
among those with pre-existing chronic illnesses. Fiscal mitigation efforts targeting at risk
households and optimal care delivery options should be considered to enhance household
resilience to COVID-19 related shocks.
, Bowen University, Iwo ,Osun State, Nigeria
Economic development extends beyond growth in per capita income to overall social
wellbeing of a country’s populace. An encompassing measure of development in the literature
is the Human Development Index (HDI). The HDI provides clarity to why countries with high
income levels are sometimes associated with poor development outcomes. HDI values
are lower in Africa relative to other regions of the world and this hampers efforts to attain
economic advancement in terms of wealth creation. While studies have examined the key
drivers of human development with varying conclusions, not much is known for countries in
the African region. This paper examines the determinants of human development in Africa
using the Human Development Index. Findings are also presented across gender using the
Gender-related Development Index (GDI).
The GDI is a distribution-sensitive measure that accounts for the human development impact
of existing gender gaps in the three components of the HDI. Focus on gender is important
because of high gender inequality in the region compared to other parts of the world. This
disparity jeopardizes the continent’s efforts for inclusive human development and economic
growth. The results are presented for the 54 countries in the region using conventional panel
data methods of the xed and random effects model. Data for the study are generated from
the Human Development Report 2019, and World Bank database 2020. The study covers the
period 1995 to 2018 based on the availability of data for GDI. The analysis is conducted for all
African countries and across country income groupings following the World Bank assignment
into Low, Lower-middle and Upper-middle-income economies.
The model specication in this study is similar to Sen’s human capital development
framework. Predictors of the HDI and GDI, includes economic growth, public spending on
education and health, Institutional quality, labor force participation, fertility rate, infrastructure
captured using ICT and environmental quality measured using Carbon emission. Positive
effects of a rise in the predictor variables are expected on the HDI and GDI with the exception
of fertility rate and carbon emission where a rise should induce negative effects on the
outcome variables, The differential impact across gender cannot be out rightly stated. The
differential effect across country income groups cannot also be out rightly stated.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University of York, York, United Kingdom, Susan Grifn, Centre for Health
Economics, University of York, United Kingdom and Simon Walker, University of York, United
Kingdom
Road trafc injuries (RTIs) are a major cause of health loss in many countries. The World
Health Organisation estimates a global 1.35 million fatal injuries and a further 20 to 50 million
non-fatal injuries annually. The abrupt nature of RTIs, treatment costs and possible disability,
has potential to impose signicant nancial pressures on households. This paper examines
the effect of RTIs on ve indicators of households’ economic wellbeing: household health
expenditure, non-health consumption expenditure, asset ownership, household indebtedness
and labour force participation. Using a multi-country household survey dataset, we employ a
mix of genetic matching and multilevel modeling techniques to isolate effects of RTIs. We also
explore use of an instrumental variable (IV) approach in a sensitivity analysis.
Estimates indicate households were worse off in several ways following a RTI; incurred
signicantly higher health expenditure, reduced expenditure on competing basic needs
and faced a higher likelihood to borrow at positive interest rates to purchase health services.
The direction of RTI effects using IV approach are consistent with those from matching and
multilevel regression. The study provides estimates of wider effects of RTIs and re-enforces the
need to consider impacts beyond the road accident victim in costing road trafc accidents.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Yewande Ogundeji Health Strategy and Delivery Foundation, Ugo Okoli, Jhpiego,
Kendra Njoku, mDoc and Mrs. Chiagozie N Abiakam, Pharm. MSc. PMP, mDoc Healthcare,
Lekki Phase 1, Lagos, Nigeria, Chigbo Chikwendu, HSDF and Yahaya Mohammed, HSDF,
Nigeria, Nigeria.
In recent times, several non-communicable diseases are becoming more implicated as indirect
risk factors for worsening maternal health outcomes in low- and middle-income countries.
Scaling up the access to the prevention, early detection, diagnoses, and management of these
NCD-related risk factors in women of reproductive age has, therefore, become imperative in
the reduction of maternal mortality and morbidity in many low- and middle-income countries
including Nigeria. However, in many countries in Africa, maternal health and NCD services
delivered in health facilities across the country are commonly fragmented and of poor quality,
which reects the traditional model of care.
A commonly recommended and contemporary strategy to address this challenge is the
innovative integration of NCD care services into routine maternal health care services. Whilst
this approach potentially has merits, there have been concerns around impact, costs (including
potential savings), scalability, and sustainability of such approaches especially in contexts with
limited/scarce resources.
Recently, a consortium of partners (funded by MSD for mothers) designed and implemented
an innovative integrated quality of care (QoC) at the subnational level in Nigeria. The QoC
model was designed as a woman-centered care model that incorporates elements of quality
improvement (strengthening of the health facility’s capacity) and self-care (leveraging digital
technology) to expand access to screening and management of hypertension, diabetes
mellitus, anemia and obesity at maternal health care touch points to reduce their contributions
to indirect causes of maternal mortality and morbidity.
The proposed organized session will present design experiences, early results, costs
implications, and lessons around sustainability within the context of scarce resources.
The rst presentation will focus on the design of the integrated model, approach to scale
up, and early results. The second presentation will describe the self-care (digital health)
intervention, including design, early results, costs implications, and critical considerations for
implementation. The third presentation will highlight cost implications and potential cost
savings from implementing an integrated model as well as experiences with the sustainability
of the approach.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Ugo Okoli, Jhpiego
Nigeria is undergoing an obstetric transition in which the proportion of maternal deaths due
to indirect causes is increasing. The attention paid to these unique vulnerabilities of women of
reproductive age (WRA) with NCDs and their risk factors has been limited to date. This abstract
describes our experience in designing and implementing a woman-centered integrated
quality of care (QoC) model focused on education, screening, detection, and management of
some of these risk factors.
Mixed methods were used to assess the prevalence of risk factors (Hypertension, Diabetes,
Anemia, and Obesity) for indirect causes of maternal mortality and morbidity in 400 women
of reproductive age. In addition, the knowledge, experience, and condence of 79 health care
workers (HCWs) in providing services for prevention and management of these risk factors in
20 health facilities were also assessed.
Stakeholders used the ndings from the assessments to design an integrated QoC model
which involved implementing screening women attending their rst ANC for high blood
pressure (HBP), anemia, and diabetes mellitus (DM) and weight status at every visit and
management of those with complications.
Assessment ndings showed a high prevalence of hypertension, anemia, obesity and to a
lesser extent diabetes mellitus in WRA screened. Less than 5% of these women were aware of
their status. In addition, many quality gaps were identied in screening and management of
NCDs, linked risk factors at the health facilities.
Our experience from implementing the integrated model of care from October 2019 to
September 2020 documented 26,712 women attending ANC at the participating facilities. The
proportion screened for hypertension, DM, and anemia during ANC increased from 35% to 71%,
11% to 65%, and 20% to 60% respectively within this one-year period.
Assessment ndings informed the design and implementation of an integrated woman-
centered QoC model of care in selected health facilities in Nigeria. The early results from
implementation are also encouraging, demonstrating improved screening for risk factors in
ANC leading to early detection and management of these complications.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Kendra Njoku, mDoc and Mrs. Chiagozie N Abiakam, Pharm. MSc. PMP, mDoc Healthcare,
Lekki Phase 1, Lagos, Nigeria
As the Nigerian health system struggles with quality of care issues, exacerbated by the
COVID-19 pandemic, preventative self-care is critical in enabling WRA to live healthier,
happier, and more productive lives, positively impacting the lives of their families and their
communities at large. In addition, with the deep penetration of smartphone ownership, digital
health technology is increasingly being leveraged to improve health processes and outcomes.
mDoc, RICOM3 consortium partner, is a digital health social enterprise that provides support to
individuals living with regular and chronic health needs with guidance on self-care and lifestyle
modications for healthier living.
This presentation will demonstrate the impact and nancial sustainability of digital health
solutions in improving self-efcacy, digital literacy, health literacy, and health outcomes among
WRA in a low-middle income setting.
Through the MSD-funded RICOM3 project, 42,126 WRA registered on mDoc’s
CompleteHealth™ platform to access coach-led multidisciplinary teams who provide self-
care support through the mDoc’s virtual omni-channel approach. Members track their health
metrics on personalized dashboards and support includes digital nudges, health education,
personalized action plans following engagement with coaches, nutritional advice, and virtual
exercise classes.
To drive nancial sustainability, mDoc conducted a conjoint pricing analysis with existing and
potential members of the CompleteHealth™ platform. A stratied random sampling method
identied 222 (141 WRA) respondents with different socio-demographics. of this
study led to the testing and deployment of tiered pricing plans enabling out-of-pocket (OOP)
payments and partnerships with HMOs to include digital self-care packages among their
health packages.
Following self-care support, WRA reported a 40% increase in self-efcacy and 14.78mmHg
average reduction in systolic blood pressure for those living with hypertension.
The conjoint pricing analysis showed access to a health specialist and specialized health coach
were the most valued features of the CompleteHealth™ platform. Five-tiered pricing plans
with different bouquet of benets were created and well received, including a freemium tier to
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
ensure access is not curbed.
To sustain these gains, reliance cannot be on external funding but on a business model that
drives nancial sustainability through partnerships with health insurance providers and out-of-
pocket payments from beneciaries of these services.
Chigbo Chikwendu, HSDF and Yahaya Mohammed, HSDF, Nigeria, Nigeria
To improve access of women of reproductive age to NCD services, an innovative integrated
model of care was recently piloted (donor-supported) at the subnational level in Nigeria with
early promising results, which has piqued the interest of potential funders for potential scale
up of the model. However, there is limited evidence on the costs of providing this integrated
package of MH/NCD care and potential approaches to sustainability, which is required to aid
policymakers, program planners, and implementers to make rational investment decisions
regarding such innovative approaches. The aim of this study was to estimate the costs of this
integrated model of care in Nigeria and to develop a viable sustainability plan.
This was a mixed methods study. First, a bottom-up micro-costing technique was used to
model costs on an excel-based cost-accounting engine developed to suit the objectives of the
costing. Potential cost savings was estimated using a cost-consequence analytic framework
to model the natural history of pregnancy progression, clinical efcacy of screening and BP
control interventions, linked pregnancy-related outcomes, and resource use, comparing the
integrated care model and the traditional model of care. Finally, a stakeholder workshop was
organized to develop a pragmatic sustainability plan to expand NCD access to women of
reproductive age.
The mean unit costs of providing the package of MH and NCD care services using the
traditional, and the integrated model of care at the PHC level were estimated to be and
₦45,419 ($148.4) and ₦46,065 ($150.5), respectively, in the FCT, and N44,137 ($144.2) and
N45,441 ($148.5), respectively. At the hospital level, the costs were N78,486 ($218) and N78,750
($257) for the traditional and integrated models, respectively in FCT, and N62,451 ($204) and
₦62,611($204.6) in Lagos State. Further analysis reects a cost savings of about ~2USD per
woman. A sustainability plan was developed across 4 domains: nancial, operational, political,
and institutional. Health maintenance organizations (HMOs) were identied as key players in
ensuring scaling and sustainability of the integrated model of care.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Estimated costs of the integrated package of care were similar to the costs of the traditional
model of care, potential cost savings with the integrated model. With at least two HMOs
indicating interest in adopting the integrated model of care, HMOs appear to have a
prominent role in ensuring sustained access of WRA to NCD services, especially in resource-
constrained settings.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Catherine Pitt London School of Hygiene & Tropical Medicine, Jacob Novignon,
Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, Yohannes
Hailemichael, The Armauer Hansen research Institute, Addis Ababa, Ethiopia, Iris Mosweu,
London School of Hygiene & Tropical Medicine, London, United Kingdom, John Solunta Smith,
PIRE Africa Center, Liberia.
Neglected tropical skin diseases (“skin NTDs”) – including leprosy, yaws, cutaneous
leishmaniasis, onchocerciasis, Buruli ulcer, and lymphatic lariasis - pose a substantial health
and economic burden in many African countries. While these diseases differ from one
another in important ways, they also share many common features; they are associated with
substantial physical disability, psychological distress, social exclusion, and nancial hardship,
and often affect people in poorer communities. The World Health Organization advocates
integrated intervention approaches, which seek to improve diagnosis, treatment, and care
for multiple skin NTDs simultaneously. Developing integrated approaches that are suitable
for each of the many contexts in which skin NTDs occur requires a nuanced understanding
of the economic impact of skin NTDs on individuals, households, and communities, as well as
the challenges and opportunities to nance integrated approaches to improve health services
for skin NTDs. Further, the efciency of integrated approaches requires assessment to inform
priority-setting decisions about if, when, where, and how they should be implemented.
This session will present new ndings from two skin NTD research programmes – SHARP,
which works in Ghana and Ethiopia, and REDRESS Liberia – both of which are funded by the
National Institute for Health Research (United Kingdom). The chair will begin the session by
briey highlighting the importance of investigating the economics of skin NTDs and providing
an overview of the structure of the session and some questions for the audience to reect on
during the presentations. Four presentations will follow. The rst two will present ndings
of qualitative studies conducted in Ghana and Ethiopia to understand how key skin NTDs in
these two countries affect patients and their families economically and the coping strategies
adopted by those affected. The third presentation will complement the rst two by focusing
on nancing challenges for skin NTDs from a health services perspective in Liberia. Drawing
on SHARP’s multidisciplinary formative work in Ghana and Ethiopia, the fourth presentation
will develop a conceptual model to guide cost-effectiveness analyses of integrated approaches
vs standard care for skin NTDs and identify some of the key issues to consider when assessing
the cost-effectiveness of integrated approaches for skin NTDs. To conclude, invited discussants
will provide initial reections on the presentations and the session chair will encourage
participation from the wider audience.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Jacob Novignon, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
Neglected tropical diseases (NTDs) of the skin - including leprosy, yaws, and Buruli ulcer -
impose a substantial health and economic burden on patients, their families, and the health
system as a whole. These NTDs result in psychological distress, stigma, and disability, as well as
a substantial nancial and economic burden. We aimed to understand the economic burden
of skin NTDs on patients and their households in Ghana, as well as the strategies adopted by
patients and caregivers to cope with these costs.
The study was conducted in the Atwima Mpunua district in the Ashanti region of Ghana as
part of wider, multidisciplinary formative research activities to inform the development of
an integrated intervention strategy. A qualitative research design was adopted, involving
the use of in-depth interviews (n=46), focus group discussions (n=7), and observations.
Both the economic questions presented here, and other topics, including stigma and
disease discourses, were explored. The sample included health workers, patients, traditional
healers, community members, and caregivers. Data were transcribed, coded, and analysed
thematically with the aid of MAXQDA software.
The results suggest substantial direct and indirect costs of experiencing and managing SSSDs.
The key direct cost drivers were wound dressing supplies, medication, and transportation.
In terms of indirect cost, both patients and caregivers reported a reduction in economic and
school-related activities. Specically, there was evidence on opportunity cost including days
lost to work, reduced working hours, lateness to school, and absenteeism. Opportunity costs
were more prevalent among female patients compared to their male counterparts. We also
found that these costs inuenced treatment choices with some patients preferring traditional
healers. In addition to their affordability, the choice of traditional healers was also attributed to
accessibility of care and exibility of payment. The main coping strategies mentioned include
dissaving, family support, community support, and the National Health Insurance Scheme
(NHIS). However, these were not widespread as not all households had consistent access to
these coping strategies.
The ndings suggest that SSSDs have economic implications for patients and their households
and this can translate into long-term consequences on living conditions. Improving medical
stock, education on appropriate health-seeking pathways, and leveraging on existing social
interventions schemes to offer soft and vocational skills for affected persons will be important
steps to reducing the economic impacts of SSSDs.
neglected tropical diseases, household costs, Buruli ulcer, yaws, leprosy
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Yohannes Hailemichael, The Armauer Hansen research Institute, Addis Ababa, Ethiopia
Cutaneous leishmaniasis and leprosy are stigmatizing skin diseases often resulting in
substantial morbidity and disability. The economic burden of these skin diseases has not been
well documented. The aim of this qualitative study was to explore the household economic
impact of cutaneous leishmaniasis and leprosy in rural Ethiopia and the strategies used by
affected households to cope with this economic burden.
The study was conducted in Kalu district, South Wollo Zone, Amhara Region of Ethiopia from
March to June 2021. It forms one part of multidisciplinary formative research conducted to
support development of an integrated intervention strategy appropriate to the local context.
Qualitative data collection explored both the economic questions presented here, and also
other topics, including stigma and disease discourses. In-depth interviews (n=98) with patients,
caregivers, and health workers; focus group discussions (n=40) with community members; and
key informant interviews (n=50) with opinion leaders, traditional healers and policy actors were
conducted. Data were coded using MAXQDA 2020 software and thematic framework was used
for analysis.
Individuals with cutaneous leishmaniasis (CL) and leprosy and their family members
experienced high cost for seeking care in the form of out-of-pocket payments, especially
for transport and accommodation. Experiencing these illnesses resulted in loss of income
to the household, through wage loss to both patients and other household members,
notably accompanying persons in care-seeking. The ndings show that children with CL
and leprosy were sometimes absent from school or withdrew from school entirely because
of their conditions. Several coping strategies including asset selling, consumption reduction,
contracting out land to be farmed, borrowing, family and community support and community-
based health insurance were used by the patient and family members to mitigate the nancial
costs of illness and production losses. Nonetheless, strategies like consumption reduction and
selling assets are more common among leprosy patients and their families.
Households in which an individual experiences CL or leprosy face substantial economic impact
in terms of lost income and time for care-seeking. Strengthening treatment and diagnostic
facilities closer to communities may increase access and reduce transport and travel costs.
Including transportation costs within nancial risk protection mechanisms may alleviate the
nancial impact.
Cutaneous leishmaniasis, leprosy, economic impact, Qualitative study, household
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
costs
Iris Mosweu, London School of Hygiene & Tropical Medicine, London, United Kingdom
Neglected tropical diseases of the skin (or “skin NTDs”) are diverse in their aetiology,
epidemiology, treatment, and health impacts; however, they also share many common factors.
They are associated with substantial physical disability, psychological distress, social exclusion,
and nancial hardship, and often affect people in the same, relatively poor communities. The
World Health Organization has advocated integrated approaches, which seek to improve
diagnosis, treatment, and care for multiple skin NTDs simultaneously; however, the efciency
of such approaches has not been widely assessed. We aimed to develop a conceptual model
to assess the cost-effectiveness of integrated case nding and management (ICF-M) strategies
compared to standard care.
To conceptualise the model, we drew on mixed methods formative research conducted in
study areas in Ghana (Ashanti region) and Ethiopia (Amhara region). We reviewed clinical and
economic evidence and engaged extensively with experts from wide-ranging disciplinary
backgrounds to understand the mechanisms by which ICF-M strategies may change care
seeking, service utilisation, downstream costs, and health outcomes. We identied key model
components and data sources for critical input parameters.
To address the decision problem, our conceptual model combines a main model, represented
with a decision tree, and sub-models for individual diseases. Although ICF-M activities target
key skin NTDs in each context – notably Buruli ulcer, yaws, and leprosy in Ghana and cutaneous
leishmaniasis and leprosy in Ethiopia – they may also increase healthcare utilisation and affect
costs and health outcomes for other skin diseases. We identied data sources to populate the
model and parameters likely to have a high level of uncertainty, which will have been identied
for sensitivity analysis. The model will project both costs and outcomes over medium to long-
term time horizons and will seek to model effectiveness in terms of both disability-adjusted
life-years and quality-adjusted life-years.
Our conceptual model will inform data collection and analysis to evaluate ICF-M strategies
implemented within the context of the Skin Health Africa Research Programme in Ghana and
Ethiopia. The conceptual model is also intended to inform cost-effectiveness analyses of ICF-M
strategies in other contexts. Identifying a model structure appropriate to reect the natural
clinical pathway of these conditions is likely to enhance model precision and transparency,
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
leading to more reliable and credible evidence to inform decision-making.
Skin diseases, Neglected Tropical Diseases, costs, cost-effectiveness, decision
modelling
John Solunta Smith, PIRE Africa Center, Liberia
Neglected tropical diseases (NTDs) are an important global health challenge, however little
is known about how to effectively nance NTD related services. Integrated management
in particular is put forward as an efcient and effective treatment modality for severe
stigmatising skin diseases (SSSD) such as leprosy, yaws, onchocerciasis, Buruli ulcer and
hydrocele. In the current study, we document barriers and facilitators to care from a health
nancing perspective.
We carried out key informant interviews with 86 health professionals and 16 national health
system representatives overall. 46 participants were active in counties implementing
integrated case management, 40 participants were active in counties implementing standard
care. We also interviewed 16 patients and community members. All interviews were transcribed
and underwent thematic content analysis.
From a health system perspective, we identify diverse challenges at national, county and
district levels. These include limited decentralization of nancial resources for NTD care and
high levels of dependence on donors. The latter are responsible for ensuring medication
availability and procurement of supplies. Government involvement in NTD nancing is
minimal, covering stafng costs only. At county and district levels, we nd limited capacity
among professionals to engage in NTD budget planning and quantication of medicines
and supplies. As donor priorities include a focus on integrated case management, extensive
piloting of the approach has taken place in 5 counties in Liberia. From the perspective of
participants, integrated case management incurs further costs compared to standard care
(including for incentivization of health professionals to engage in NTD activities); however,
service outputs in pilot counties are also higher. Motivation of staff across pilot counties to
engage in NTD work is also high, however late salary payments compromise staff motivation
across all counties and lead to high levels of non-attendance or attrition. To date, despite the
fact that services are meant to be free at point of care, neither pilot nor non-pilot counties
cover all necessary patient incurred costs. From a patient and community perspective, we
identify patients frequently paying for medication and supplies due to stockouts. Patients also
pay for transportation to health facilities; as motorbike rides also frequently refuse to transport
SSSD patients, out of pocket expenses are high.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Our ndings accord with broader work on nancing of SSSD services in West African settings
and suggest that health economic evaluations of integrated care approaches vs. standard care
are warranted.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Bryony Simmons1, Elisa Sicuri2 and Lesong Conteh1, (1)London School of Economics &
Political Science, London, United Kingdom, (2)London School of Economics & Political Science,
United Kingdom, Zoly Rakotomalala1, Jean-Marc Kutz2, Raphael Rakotozandrindrainy3,
Tahinamandranto Rasamoelina4, Rivo Rakotoarivelo5 and Daniela Fusco2, (1)Centre
Hospitalier Universitaire de Mahajanga, Madagascar, (2)Bernhard Nocht Institute for Tropical
Medicine, Germany, (3)University of Antananarivo, Madagascar, (4)Centre d’Infectiologie
Charles Merieux, Madagascar, (5)Centre Hospitalier Universitaire de Fianarantsoa,
Madagascar, Marie Paul Nisingizwe1, Jean Damascene Makuza1, Bethany Hedt-Gauthier2,
Janvier Serumondo3, Eric Remera3, Sabin Nsanzimana3, Naveed Janjua1, Nick Bansback1
and Michael Law1, (1)University of British Columbia, Canada, (2)Harvard Medical School, (3)
Rwanda Biomedical Centre, Rwanda, Rose Nadege Penda Noelle Mbaye1, Fatoumata Diene
Sarr2, Hamidou Thiam2, Rokhaya Diop2, Mam Coumba Diouf2, Mohamed Abass Yugo2,
Ahmed Badji3, Ahmadou Bouya Ndao4, Abdoul Kane5, Amadou Alpha Sall2 and Cheikh
Loucoubar2, (1)Institut Pasteur of Dakar, Dakar, Senegal, (2)Institut Pasteur of Dakar, Senegal,
(3)Département socio-anthropologie université Cheikh Anta Diop de Dakar, Senegal, (4)
District Sanitaire de Sokone, Senegal, (5)Clinique cardiologie de l’hôpital le Dantec, Senegal
Francesco Ramponi1, Pakwanja Twea2, Benson Chilima2, Dominic Nkhoma3, Isabel Kazanga
Chiumia3, Gerald Manthalu2, Joseph Mfutso-Bengo3, Paul Revill1, Mike Drummond4 and
Mark Sculpher4, (1)Centre for Health Economics, University of York, York, United Kingdom, (2)
Ministry of Health, Malawi, (3)Health Economics & Policy Unit (HEPU), College of Medicine,
University of Malawi, Malawi, (4)Centre for Health Economics, University of York, United
Kingdom.
Accurate diagnostic tests are central for the management of communicable and non-
communicable diseases at both the patient level (eg, for the diagnosis, guided therapy, and
management of disease) and the population level (eg, for disease detection and surveillance).
The availability and timely access to diagnostics are therefore essential to reducing the
burden of disease and contributing towards health system strengthening and sustainable
development. Despite this, access to appropriate and quality disease diagnostic testing is poor
and inequitable in many parts of the world.
Diagnostic value chains or frameworks have been proposed to understand the chain of events
between the design and development of a new diagnostic testing device and its adoption
by end users. Challenges to the demand and supply of diagnostics exist across all steps of
this value chain, with each representing a potential point of failure for successful adoption of
technologies. These challenges are compounded by a lack of reliable and comprehensive data
to inform planning and support policy decisions.
This session will discuss the diagnostics value chain, focusing largely on diagnosis of infectious
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
diseases, highlighting the main steps from inception to utilisation, and expanding on
challenges and key data gaps. Using evidence from different settings across Africa and a range
of disease areas, the session will then draw examples addressing challenges of demand and
supply in disease diagnoses along the continuum, highlighting context-specic challenges
and solutions.
Bryony Simmons1, Elisa Sicuri2 and Lesong Conteh1, (1)London School of Economics & Political
Science, London, United Kingdom, (2)London School of Economics & Political Science, United
Kingdom.
Broad access to rapid and accurate diagnostic tools is essential for the tracking, testing, and
treatment of infectious diseases. Despite this, access to appropriate diagnostics often remains
poor and inequitable. These issues are compounded by a lack of data across the diagnosis
continuum to inform demand, innovation, and the delivery of coherent cost-effective policy.
The primary aim is to propose a simple continuum for infectious disease diagnosis, from
design through to implementation. Key challenges to diagnostics demand and supply along
the continuum will be highlighted, focusing on the identication of data gaps to inform
planning and policy. Special emphasis will be applied to meeting the needs of countries across
sub-Saharan Africa.
This is a cross-sectional study using a survey distributed online through the Qualtrics platform
to identify key data gaps and potential solutions across the diagnosis continuum. The survey
is informed by a conceptual framework for introducing diagnostic tools, researched and
proposed as part of the study. After piloting and rening the survey, individuals involved in a
broad range of activities relating to infectious disease diagnosis will be invited to participate.
Participants include programme ofcers, policymakers, clinicians, laboratory technicians,
diagnostic manufacturers, international organisations, donors, and researchers. The survey will
not focus on individual diseases specically, rather, it will focus broadly on data gaps across
infectious diseases. Data will be analysed using a combination of quantitative and thematic
analysis, focusing on data gaps and potential solutions to better inform decision-making.
Various frameworks for conceptualising the diagnosis continuum have been proposed, largely
focusing on point-of-care infectious disease diagnostics. Common elements were used to
guide survey questions. These were: i) assessment of need/demand; ii) product feasibility,
design, and development; iii) validation and manufacturing; iv) planning, regulatory approvals,
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
and launch; and v) adoption, scale-up, and impact measurement. Stakeholders responding
to the survey identied key data gaps along the continuum, impacting on the successful
development and adoption of diagnostic technologies. These will be discussed in detail along
with potential solutions to better inform infectious disease diagnosis planning and policy.
Dening a continuum for infectious disease diagnosis is useful to highlight the data gaps
and barriers mapped to particular stages of the continuum, and to assess their impact on
the successful adoption of appropriate diagnostics. These ndings highlight opportunities to
mitigate data and research gaps and strengthen data generation and dissemination to inform
policy and planning.
Zoly Rakotomalala1, Jean-Marc Kutz2, Raphael Rakotozandrindrainy3, Tahinamandranto
Rasamoelina4, Rivo Rakotoarivelo5 and Daniela Fusco2, (1)Centre Hospitalier Universitaire
de Mahajanga, Madagascar, (2)Bernhard Nocht Institute for Tropical Medicine, Germany,
(3)University of Antananarivo, Madagascar, (4)Centre d’Infectiologie Charles Merieux,
Madagascar, (5)Centre Hospitalier Universitaire de Fianarantsoa, Madagascar.
Female genital tract disorders are high burden conditions especially in Low- and Middle-
Income Countries (LMICs). These disorders include a wide spectrum of medical conditions
spanning from sexual transmitted infections, parasitic diseases and cancer among others.
Prevention is the most powerful tool to ght many of these disorders. Screening programs
exist, but in LMICs they have three main barriers: accessibility, applicability and social stigma.
For a better accessibility, the promotion of services at primary level of care is crucial but, in
absence of easy to use diagnostics, the applicability of these services is limited. Social barriers
limit the accessibility to services, due to stigma, fear and cultural beliefs. Integrated solutions
addressing these conditions within existing programs, such as anti-natal care services could
address in parallel the main barriers for their management.
Schistosomiasis is a Neglected Tropical Disease (NTD) caused by the trematode Schistosoma
and leading to chronic medical conditions such as Female Genital Schistosomiasis (FGS).
Cervical cancer (CC) is one of the most common HPV-related diseases. Infections with HPV can
naturally resolve or lead to CC through a long-term asymptomatic period. Both diseases are
particularly prevalent in Africa, with Madagascar one of the countries with the highest burden
of schistosomiasis worldwide.
Our study aimed at assessing the feasibility and applicability of a screening program for CC,
HPV and FGS at primary level of care in rural Madagascar.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
After performing a baseline assessment on the awareness of FGS among Health Care Workers
(HCW, n=93) and the general population (n=727), through a mixed-methods approach, we
performed an awareness campaign. Afterwards, screening services where offered to a total
of 500 women at three primary health care centers of the region of Boeny in Madagascar:
Marovay (peri-urban), Antanambao-Andranolava (rural) and Ankazomborona (rural). In-depth
interviews were conducted among HCW and women included in the program to explore the
service usability and satisfaction from both users and providers perspectives.
Our preliminary data show that the awareness of FGS among both HCW (n=50, 54%) and the
general population (n=644, 88%) low. In addition, among the 500 women to whom a screening
service was offered, 483 (96.6%) accepted.
The preliminary analysis of our intervention, shows a good acceptability of gynecological
screening in our study population. We can speculate that the awareness campaign improved
acceptability supporting the concept that health literacy represents a crucial element to
promote prevention.
Marie Paul Nisingizwe1, Jean Damascene Makuza1, Bethany Hedt-Gauthier2, Janvier
Serumondo3, Eric Remera3, Sabin Nsanzimana3, Naveed Janjua1, Nick Bansback1 and
Michael Law1, (1)University of British Columbia, Canada, (2)Harvard Medical School, (3)Rwanda
Biomedical Centre, Rwanda
Though it is well known that timely diagnosis and delivery of antiviral therapy can cure and
prevent progression to later stages of disease, access to hepatitis C (HCV) diagnosis and
treatment has been limited. Sub-Saharan Africa (SSA), is home to almost 20% of global HCV
infections, yet access to services remains very challenging due to limited health system
resources. Over the past 20 years, Rwanda has improved access to health care services across
numerous indicators. However, less than 1% of HCV patients were on treatment in 2015. To
address this, the Government of Rwanda launched a voluntary mass screening and treatment
campaign in 2016. As part of the scheme, patients with a conrmed diagnosis are initiated on
treatment free-of-charge. As the rst screening and treatment program implemented in SSA,
it is crucial to evaluate whether this effort has achieved its goal of improving access to HCV
care services and reduced HCV burden.
This study aimed to 1) describe characteristics of patients screened and treated during the
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
mass screening and treatment campaign 2) describe the cascade of care for HCV patients and
identify factors associated with drop-out 3) estimate the proportion of patients who achieved
sustained virologic response and identify factors associated with treatment failure.
We conducted a retrospective cohort study and used secondary data to describe the cascade
of care and assess factors associated with treatment failure and drop-out. A retrospective
review of medical records was carried out to determine patients testing results and treatment
outcomes. The data from patients’ charts was combined with screening electronic database
compiled during the antibody testing. We generated descriptive statistics to estimate total
number of patients screened and their characteristics and the proportion of 1) treatment
success and failure 2) completion at each stage of care. We used mixed effects logistic
regression to assess factors associated with HCV positivity, gaps in care and treatment failure.
Analysis is still ongoing, and ndings will be available at the time of the conference.
This study provides evidence on who was screened during the mass campaign and HCV
patients’ characteristics. It also provides evidence on which interventions would be more
impactful on the successful treatment of patients with HCV or the level of care that need more
responses. The lessons learned from this study can be utilized by ofcials in other countries
with similar settings that are looking to initiate HCV programs.
Rose Nadege Penda Noelle Mbaye1, Fatoumata Diene Sarr2, Hamidou Thiam2, Rokhaya
Diop2, Mam Coumba Diouf2, Mohamed Abass Yugo2, Ahmed Badji3, Ahmadou Bouya
Ndao4, Abdoul Kane5, Amadou Alpha Sall2 and Cheikh Loucoubar2, (1)Institut Pasteur
of Dakar, Dakar, Senegal, (2)Institut Pasteur of Dakar, Senegal, (3)Département socio-
anthropologie université Cheikh Anta Diop de Dakar, Senegal, (4)District Sanitaire de Sokone,
Senegal, (5)Clinique cardiologie de l’hôpital le Dantec, Senegal.
According to WHO projections, the annual number of deaths from non-communicable
diseases will reach 55 million by 2030 if nothing changes. In Senegal, according to national
surveys done in 2015, 9.4% of adults (18-69 years) had three or more cumulative cardiovascular
diseases risk factors and more than 29.8% of the adult population had high blood pressure.
Senegal, through its Health and Social Development Plan 2019-2028, plans to reduce
morbidity/mortality due to cardiovascular diseases and risk factors. To respond to this national
priority, population-based screening and referral strategies relying on community health
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
workers can be targeted.
To facilitate access to diagnostic services of cardiovascular diseases risk factors and to improve
case management through community-based screening approaches.
A cross-sectional study between December 2020-March 2021 was put in place in the two rural
communities of Dielmo and Ndiop-Fatick Region, Senegal. The cardiovascular disease risk
factors screened for were: Body Mass Index (BMI), arterial hypertension (AH), hyperglycemia,
hyperlipidemia and current and previous tobacco use using point of care tools such as nger
prick test. Analysis of sociodemographic, clinical, and biological data was performed with Excel,
R, and Stata software; analysis of socio-anthropological data was performed with Kobotoolbox,
Excel, Atlas Ti, or Nivo software.
The participation rate was 89.5% (561/680) among community members aged 18 years or older.
75.0% of participants had at least one risk factor for cardiovascular disease. Dyslipidemia was
the most common risk factor (87.6%) and 86.7% had hypoHDLemia. 35.2% of those screened
had hypertension, and 6.7% had obesity. Smoking and hyperglycemia were diagnosed in
less than 5% of the participants. Further tests (ECG and ultrasound) among participants
who scored high on the Framingham Risk Score for Hard Coronary Heart Disease revealed
9% of participants who were found with preciously unknown and untreated abnormal heart
functions.
The study reveals a high prevalence of cardiovascular disease risk factors in rural areas in
Senegalese and demonstrating that community-based screening by community health
workers can increase access diagnosis and early case identication.
Francesco Ramponi1, Pakwanja Twea2, Benson Chilima2, Dominic Nkhoma3, Isabel Kazanga
Chiumia3, Gerald Manthalu2, Joseph Mfutso-Bengo3, Paul Revill1, Mike Drummond4 and
Mark Sculpher4, (1)Centre for Health Economics, University of York, York, United Kingdom, (2)
Ministry of Health, Malawi, (3)Health Economics & Policy Unit (HEPU), College of Medicine,
University of Malawi, Malawi, (4)Centre for Health Economics, University of York, United
Kingdom.
Health systems face a broad range of policy decisions related to new potentially valuable
technologies, including diagnostics tools. These decisions relate to the different stages
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
through which a technology must pass, from being identied as a potentially viable option
within a health care system, to being implemented at scale to provide the greatest impact on
population health net of the opportunity costs associated with its funding. Health technology
assessment (HTA) offers a set of analytical tools to support health systems’ decisions about
resource allocation. Although there is increasing interest in these tools across the world,
including in some middle-income countries, they remain rarely used in low-income countries
(LICs). In general, the focus of HTA is narrow, mostly limited to assessments of efcacy and
cost-effectiveness. However, the principles of HTA can and should inform the whole range of
policy decisions regarding new health technologies.
We examine the potential for this broad use of HTA in LICs, with a focus on Malawi. We
develop a framework to classify the main policy decisions on health technologies within
health systems. The framework covers decisions on identifying and prioritising technologies
for detailed assessment, deciding whether to adopt an intervention, assessing alternative
investments for implementation and scale-up, and undertaking further research activities. We
explore the value and implications of the framework by applying it in the Malawian context,
and mapping each policy decision point to the local health system and governance structure.
Using two contrasting health technologies as examples, we outline how decisions are currently
made, investigate the current use of HTA and explore to what extent it could further assist
local decision-makers. More specically, we describe how decisions were addressed when
introducing CT scanners in the Malawian health system, and we show mechanisms by which
evidence can enter policy deliberations using a diagnostic tool, HIV self-testing, as an example.
Although the scarcity of local data, expertise, and other resources could risk limiting the
operationalisation of HTA in LICs, we argue that even in highly resource constrained health
systems, such as in Malawi, the use of HTA to support a broad range of decisions is feasible and
desirable. The CT scanners and HIV self-testing examples show that an absence of appropriate
evidence and analysis can lead to decisions that are detrimental to population health.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Charles Ebikeme London School of Economics / AHOP
The COVID-19 pandemic has highlighted the importance of integrating knowledge for health
systems decision-making. For the most impact, re-engineering health systems requires
knowledge to be used effectively.
The aim of this panel will be to explore the various working methods used to help bridge the
gap between research, policy, and practice in development efforts in Africa. This is especially
pertinent given the growing need for health research to be suitably channeled into policy and
for practice to be meaningfully transformed.
The panel will highlight the role of policy-makers in the process of evidence production. It
will showcase how the African Health Observatory Platform on Health Systems and Policies
(AHOP) functions to produce knowledge that is responsive to policy-maker needs and
priorities. AHOP produces a suite of products including Country Health System & Services
Proles (CHSSPs), policy briefs, comparative and thematic studies, and policy dialogues that
benet from policy-maker input.
The discussion will present perspectives from both the AHOP research community and
government representatives within the greater AHOP collaborative, as well as other knowledge
brokering platforms that aim to promote evidence-informed policy-making for health systems
within the African region.
The discussion will also highlight how each group brings valuable and necessary knowledge
resources to enrich research, decision-making, and action. Some of the challenges involved
in multi-stakeholder knowledge generation will be examined, with an emphasis on the non-
linear pathway that exists from research to policy use.
During this panel session, speakers will engage on some of the institutional, structural,
and cultural challenges to evidence generation and use. Participants will showcase efforts,
activities, and initiatives that have led to impact, change, and long-term engagement on
health policy issues from the wider stakeholder and decision-making community. The panel
will feature representatives from AHOP National Centres, the WHO Regional Ofce for Africa
(AFRO), WHO Country Ofces in the African region, and Ministries of Health, alongside other
Knowledge Exchange Platforms and will reect on the collaborative efforts at the centre of this
partnership. The discussion will explore how the various activities undertaken by AHOP have
been guided by policy maker input.
The discussion will be followed by an audience Q&A.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Distributional Benet-Cost Analysis of Rotavirus Vaccine Coverage in Uganda
Rornald Muhumuza Kananura1, Gatien de Broucker2, Ema Sam Arinaitwe3, Samantha Sack2,
Athony Ssebagereka1, Aloysius Mutebi1, Elizabeth Ekirapa Kiracho1 and Bryan Patenaude4, (1)
Makerere University School of Public Health, Kampala, Uganda, (2)Johns Hopkins Bloomberg
School of Public Health, Department of International Health, Baltimore, (3)Ministry of Health,
Kampala, Uganda, (4)Johns Hopkins Bloomberg School of Public Health, Department of
International Health, Kampala, Uganda
Diarrhea is the second leading cause of death among children under 5 years of age
contributing to 8% of global all-cause mortality in 2017. Past studies have shown that a majority
(approximately 45-65%) of childhood diarrheal morbidity and mortality is caused by rotavirus,
which is vaccine preventable. Initially planned for 2016, the rollout of the rotavirus vaccine by
the Ministry of Health in Uganda started in 2018. In this study we estimate the economic and
health impact of the rotavirus vaccine rollout in Uganda considering equity in health outcomes
in one of the rst distributional benet-cost analyses conducted in eld of global public health.
Building on Distributional Cost-Effectiveness Analysis (DCEA) methods by Asaria, Grifn and
Cookson, we integrate a valuation of non-health costs inclusive of indirect costs: neither DCEA
and Expanded Cost-Effectiveness Analysis (ECEA) incorporate non-health benets (DCEA) or
costs beyond out-of-pocket payments (ECEA). We estimated the baseline health distribution
and modeled changes attributable to the rotavirus vaccine with data drawn from modeling
estimates of the Vaccine Impact Modeling Consortium. Data on the rotavirus vaccine rollout,
including vaccine coverage, doses delivered, vaccine cost, and demographic information on
the vaccine recipients come from UNEPI and the Ministry of Health of Uganda. Economic
burden data for Uganda used for valuation come from the Decade of Vaccine Economic
project with primary data collection conducted in 2017-18.
Treating an acute diarrhea case costed $7 and $15 (if it required hospitalization) in medical
costs, of which 67-73% were covered by the government in public healthcare facilities.
Including non-health costs, the societal economic cost of a case climbed to $14 and $53
(hospitalized). About 49% and 71% (hospitalized) of the economic cost were non-health
costs. Additionally, we nd that the economic burden of diarrhea disproportionately affects
households in the poorest socioeconomic strata (SES): over 53% of households in the poorest
wealth quintile experienced catastrophic health expenditures, compared to 31% of those in the
wealthiest quintile. Further results on the distributional impact of rotavirus will be available in
the rst quarter of 2022.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
By including non-health and indirect costs in addition to monetizing the health outcomes,
DBCA may provide better framework than cost-effectiveness analysis when the goal is to
compare health investments with non-health investments. The ability to conduct DBCA will
be integrated to the Vaccine Economic Research for Sustainability and Equity toolkit, for
generation of country-specic cost-benet estimates and equity metrics.
1, Nwanneka Ghasi2, Uchenna Okenwa3, Nnanna Nwangwu4, Uchenna
Ezenwaka2 and Obinna Onwujekwe5, (1)University of Nigeria Enugu Campus, Enugu, Nigeria,
(2)University of Nigeria Nsukka (Enugu Campus), (3)Enugu State Ministry of Health, (4)Enugu
State University of Science and Technology, (5)University of Nigeria, Nsukka, Enugu Campus,
Enugu, Nigeria
Notwithstanding that weak accountability poses a signicant barrier to performance of routine
immunization systems and high immunization coverage in low- and middle-income countries,
studies on accountability of immunization programmes are scare. This study assessed how
contextual factors and roles and interaction of different actors affect data quality and use of
data for decision making to improve internal accountability in immunization services.
We used semi-structured interviews to collect data from routine immunization ofcials at
state, local, and health facility levels (n = 35) in Enugu State in South-East Nigeria between June
and July 2021. We adopted maximum variation sampling to select individuals with roles and
responsibilities as immunization data producers and data users. The in-depth interview guide
explored internal accountability within immunization system guided by dynamic dimensions
of accountability in health systems along the axes of power, ability, and justice. Data was
analysed thematically using NVivo software (version 11).
Inconsistent use of appointment letters and job description and inadequate orientation of
staff limited the ability to support change. Multiple and conicting roles of facility staff, too
many tools, and inadequate training constrain data quality. Although performance standards
exist, weak capacity to manage immunization data limits how targets are set or met.
Despite use discretions to ll resource gaps, managerial decision space is narrow. Infrequent
supervision and poor funding limit the use of supervision to ensure accountability. Weak
supervisory feedback mechanism, inconsistent use of monitoring charts, and irregular data
review meetings constrain data use. Inadequate stafng, maldistribution, high workload,
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
and absenteeism hinder immunization data quality and use. Regarding axis of power to
spark change, limited nancial incentives, salary disparities, insecure work environment, and
interrupted supply of working materials demotivate immunisation ofcials. Low enforcement
of sanctions, fear of victimization and political interference threaten the functioning of
accountability relationships. In terms of axis of justice, local political leaders have low priority for
routine immunization and tend to be more responsive to issues championed at the state level.
While community interaction improves uptake of immunization services, and engagement
of volunteer health workers, HFC leaders lack capacity to interpret monitoring chart, and the
power to hold health workers accountable.
Internal accountability of immunization programme in Enugu State, Nigeria is weak. The study
has identied the factors that can be considered in the design of interventions to address the
internal accountability challenges in a sub-national immunization programme.
, Sandema Hospital, Bolgatanga, Ghana, Gifty Apiung, University for
Development Studies, Tamale, Ghana and Natasha Howard, London School of Hygience and
Tropical Medicine, London
The COVID-19 pandemic has spread to all parts of the world including Ghana. It has resulted
in over 4 million deaths worldwide including deaths among nurses and other health-workers
at the frontlines of the pandemic response. Precautionary measures in Ghana now include
AstraZeneca vaccine. However, studies on factors affecting uptake of COVID-19 vaccines in
Ghana are limited. Therefore, this study aimed to analyse knowledge, attitudes, and uptake
of AstraZeneca vaccine among nurses in the War Memorial Hospital, Navrongo, Upper East
Region, Ghana. We conducted a descriptive cross- sectional study, randomly sampling 128
nurses aged 21-50 years using paper questionnaires. Results revealed all 128 respondents
had heard of the AstraZeneca vaccine but only 54% had knowledge of it. Attitudes toward
the vaccine were generally positive (53.1%) and uptake was very good (71.9%). Factors cited
by the 28.1% who declined the vaccine included already having been infected with COVID-19,
absence during vaccination, lack of trust in vaccine safety or efcacy, or pregnancy and
breastfeeding. Multivariable logistic regression analysis revealed that demographic factors
were not associated with nurses’ knowledge of the COVID-19 vaccine (AOR=0.89; 95% CI=0.28-
2.85). Educational status was the only factor associated with nurses’ positive attitude towards
COVID-19 vaccine uptake (AOR=8.09; 95% CI=2.23-29.36). The Ghana Health Service should
provide regular COVID-19 testing and vaccination services for nurses and other health-
workers, while increasing COVID-19 information campaigns for health-workers in Upper East to
strengthen existing knowledge and vaccine uptake.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Sulaiman Saidu Bashir2, Husayn Muhammad Mahmud1, Paul
Sale Margwa2, Esly Emmanuel3 and Zubaida Hassan4, (1)Federal College of Education Yola,
Nigeria, (2)Adamawa State Primary Health Care Development Agency, Yola, Nigeria, (3)
Adamawa State Rural Water Supply and Sanitation Agency, Yola, Nigeria, (4)Department of
Microbiology Modibbo Adama University, Yola, Nigeria
The COVID-19 Pandemic, regarded as the worse disaster since the great depression in the
1930s, has affected critical sectors of human development, globally. The health system was
unprepared for it. Thus, the development of the COVID vaccine was a ray of hope. COVID
vaccination was rolled out in Nigeria in March 2021. However, despite vaccination being one of
the most cost effective intervention, the uptake and coverage of COVID-19 vaccine has been
sub-optimal, due to some supply and demand factors.
This study aims to access the level of uptake and coverage of the COVID-19 vaccines across the
36 states of Nigeria, and the Federal Capital Territory (FCT), Abuja.
Secondary data review was conducted using data from the COVID-19 Vaccine database in
Nigeria (COVID-19 Vaccination National Daily Call-in- Data). Furthermore, a desk review of
literature on COVID-19 vaccine hesitancy and apathy in developing countries was conducted.
Findings were then triangulated.
The uptake of the COVID-19 vaccine in Nigeria as of 23rd October 2021 was only 5.0% of the
targeted population. For the rst dose of the vaccine, a total of (n=111,776,503) persons were
targeted nationwide. However, only 5,539,012 were vaccinated as of 23rd October 2021. Similarly,
only 2.6% (n=2,895,121) of the population were vaccinated for the second dose. State-wise
coverage of COVID-19 vaccine as a proportion of eligible fully vaccinated individuals indicated
that; (1) Zamfara State and FCT have the highest coverage record with AstraZeneca phase 1 and
2 with 75% and 71%, respectively. Osun and Ondo States recorded the lowest coverage of the
same vaccine with 40% and 34%, respectively. (2) Highest coverage of Moderna vaccine on the
other hand was reported from Lagos and Adamawa States with 74%, and 73%, respectively. The
lowest coverage of Moderna vaccine was 21% and 20% coverage reported in Kogi and Bayelsa
States respectively.
There is a great variation in the uptake and coverage of COVID-19 vaccine in Nigeria. The
policy implication for the study is the promotion of behaviour and communication practice,
especially in the areas/states identied with low coverage. Strict application of the OECD Trust
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Framework will lead to improvement in both utilisation and uptake of COVID-19, and future
related vaccination in the country.
Uptake, Coverage, COVID-19 Vaccination, Nigeria
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Brian Asare2, Martha Gyansa-Lutterodt3, Joycelyn Naa Korkoi Azeez3 and
Justice Nonvignon1, (1)Department of Health Policy, Planning and Management, School of
Public Health, University of Ghana, Legon, Ghana, (2)Ministry of Health, Accra, Ghana, (3)
Ministry of Health, Ghana, Accra, Ghana
In addition to the various measures put in place to control and prevent further spread of
COVID-19, Ghana started vaccination in March, 2021. Vaccination of the population is one of the
strategic measures the country has adopted in line with global practice. This study estimated
projected cost of COVID-19 vaccine introduction and deployment in Ghana.
Using the COVID-19 vaccine introduction and deployment costing (CVIC) tool developed by a
range of partners including WHO and UNICEF, Ghana’s Ministry of Health Technical Working
Group for Health Technology Assessment (TWG-HTA) in collaboration with School of Public
Health, University of Ghana, organized an initial two-day workshop that brought together
partners to deliberate and agree on input parameters to populate the CVIC tool. We had
a further 2-3 day validation with the EPI and other partners to nalize the analysis. Three
scenarios, with different combinations of vaccines and delivery modalities, as well as time
period were used. The scenarios included AstraZeneca (40%), J & J (30%), Moderna, Pzer, and
Sputnik V at 10% each; with full vaccination by second half of 2021 (Scenario 1). AstraZeneca
(30%), J & J (40%), Moderna, Pzer, and Sputnik V at 10% each with full vaccination by rst half
of 2022 (Scenario 2). Equal distribution (20%) among AstraZeneca, J & J, Moderna, Pzer, and
Sputnik V; with full vaccination by second half of 2022 (Scenario 3).
The estimated total cost of COVID-19 vaccination ranges between $348.7-$436.1 million for
the target population of 17.5 million (i.e., 57% of the population). These translate into per fully
vaccinated person cost of $20.9-$26.2 and per dose (including vaccine cost) of $10.5-$13.1. Again,
per fully vaccinated person excluding vaccine cost was $4.5 and $4.6, thus per dose excluding
vaccine also ranged from $2.2–$2.3. The main cost driver was vaccine doses, including
shipping, which accounts for between 78%-83% of total cost. Further, an estimated 8,437-
10,247 vaccinators (non-FTEs) would be required during this period to vaccinate using a mix of
delivery strategies, accounting for 8%-10% of total cost.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
COVID-19 vaccine deployment and introduction is estimated to cost about 61%-76% of Ghana’s
2021 health sector budget allocation for non-remuneration activities and projects. Efforts are
required to mobilize the required resources to vaccinate the population against COVID-19, and
these ndings provide the estimates to inform resource mobilization efforts by government
and other partners.
, ICAN West Africa Hub, Lagos, Nigeria, Shola Tanimowo, Ibeju-Lekki
LGA, Lagos State, Lagos, Nigeria, Abosede Ajadi, Department of Sociology, University of Lagos,
Lagos, Nigeria, Chidumga Ohazurike, Department of Community Health, Lagos University
Teaching Hospital, Lagos, Nigeria, Chinyere Cecelia Okeke, HPRG, Enugu, Nigeria, Obinna
Onwujekwe, University of Nigeria, Nsukka, Enugu Campus, Enugu, Nigeria and Benjamin
Chudi Uzochukwu, University of Nigeria Enugu Campus, Enugu, Nigeria
Missed opportunities for vaccination (MOV) contribute to low immunization coverage rate
in Nigeria and other African countries. Its prevalence in Africa ranged between 47.0-62.1%.
Addressing MOV was shown to improve immunization coverage rate by 10-30% and very
critical for achieving immunization agenda 2030 (IA2030) where everyone fully benets
from vaccines for good health and well being. However, there is paucity of data on MOV in
Lagos State, Nigeria, where immunization coverage rates dropped below 60% in some Local
Government Areas (LGAs) in 2020. This study aimed at determining the prevalence, identifying
factors leading to and developing strategies for reducing MOV in selected health facilities in 5
LGAs of Lagos State.
This was a cross-sectional study using mixed methods for data collection in May 2021. Among
health workers and caregivers, 600 exit interviews, 300 KAP interviews, 30 key informant
interviews and 10 focus group discussions and a brainstorming session were conducted.
Quantitative data collected by ODK was analyzed using SPSS version 22 and presented in
tables as frequencies and proportions and also in charts. Qualitative data was analyzed
thematically and the emerged themes were reported. Ethical approval for the study was
obtained from the Lagos University Teaching Hospital Health Research Ethics Committee.
The prevalence of MOV ranged between 3-31%. Second dose of Measles vaccine accounted for
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
21% of the total eligible doses missed. About 4 in 5 of the health workers had poor knowledge
of absolute contraindications for vaccines. A third of the health workers knew about checking
the immunization status of any child making contact with the health facilities. About 4 in 10 of
the health workers will instruct caregivers to always come with the child health card for every
facility visit. Factors associated with MOV include the age of the child, purpose of facility visit,
classication and the LGA of the health facility. Reasons for MOV include lack of exibility in the
facility immunization schedules, failure of screening for immunization status by health workers,
poor knowledge of eligibility criteria for immunization by health workers, concerns about
vaccine wastage and vaccine hesitancy.
Prevalence of MOV was substantial resulting from factors associated with the health system
and caregivers. Strategies addressing the health system challenges such as strengthening the
integration of PHC services, reinforcement and capacity building of the health workforce may
help in reducing MOV and improving immunization coverage rate, towards the achievement of
IA2030.
1, Omobolaji Orefejo2, Oluwayomi Adeleke3, Olubunmi Akinlade2,
Adanma Ekenna4, Ijeoma Okoronkwo5 and Obinna Onwujekwe6, (1)Department of
Community Health, Lagos University Teaching Hospital, Lagos, Nigeria, (2)Lagos State Primary
Health Care Board, Lagos, Nigeria, (3)Department of Sociology, University of Lagos, Lagos,
Nigeria, (4)Health Policy Research Group, University of Nigeria, Enugu Campus, Enugu State,
Nigeria, (5)University of Nigeria, Enugu Campus,, Enugu State, Nigeria, (6)University of Nigeria,
Nsukka, Enugu Campus, Enugu, Nigeria
The generation of quality immunization data at the sub-national levels especially at the health
facility level is essential for prioritizing and tailoring strategies to address immunization gaps
and contribute to the overall success of immunization programs in low- and middle-income
countries. A rapid review of routine immunization data in Lagos State for the year 2020
revealed that 13 out of the 20 LGAs in the State had inappropriate data accuracy ratios for the
Penta 3 antigen. We aimed to assess the accuracy, completeness, timeliness and quality index
of routine immunization data using the Penta 3 vaccine as well as the enablers and barriers to
the collection and use of quality immunization data in four Local Government Areas in Lagos
State.
This was a cross-sectional descriptive study using mixed methods for data collection in
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
May 2021. A survey of 68 facilities and 30 interviews (22 KIIs and 8 FGDs) were conducted.
Quantitative data collected by ODK was analyzed using SPSS version 22 and presented in
tables as frequencies and proportions and also as charts. Qualitative data was analyzed
thematically and emerged themes were reported. Ethical approval for the study was obtained
from the Lagos University Teaching Hospital Health Research Ethics Committee.
The accuracy ratio ranged between 17.6%-88.2% and 35.3%-82.4% at the health facility and
LGA levels while the community accuracy ratio ranged between 72.8%-90.4% respectively. The
completeness and timeliness of reports was 100% for health facilities in two of the four LGAs.
Quality index scores varied in different components of the monitoring system with evidence of
using data having the lowest index score at both health facility and LGA levels. Some enablers
of quality immunization data include training, supportive supervision, communication of
feedback, provision of stipends for internet and airtime and data validation meetings while
recurring barriers were poor work experience, staff attrition, high work overload, competing
programs, cumbersome data tools and poor workers’ attitude.
The low data accuracy ratio and QI scores reported in this study point to important challenges
to be addressed in order to improve the quality of immunization data in Lagos State. It is
therefore necessary to build the capacity of frontline health workers to understand the
importance of generating accurate data, taking ownership of the data generated and using
same to improve immunization decision making in their health facilities and LGAs respectively.
immunization, quality, data, accuracy ratio, quality index.
, Catholic University of Cameroon(CATUC), Bamenda, Department of
Health Economics, Policy and Management, Bamenda, Cameroon, Prof. Mbacham Wilfred
Fon, Biotechnology center, University of Yaounde, Yaounde, Cameroon, Dr. Promise Aseh
Munteh, Catholic University of Cameroon, Bamenda, Cameroon and Dr. Bereynuy Jude(MD)
Cholong, Catholic University of Cameroon, Bamenda, Bamenda, Cameroon
Like most vaccines, Covid-19 vaccines can cause side effects, most of which are mild or
moderate and might go away within a few days. Other results of clinical trials, however,
revealed that more serious or long-lasting side effects are possible.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
This work aimed at comparing the risk and odds of dying from Covid-19 vaccination with dying
from its infection.
This work made use of secondary data from the Centre of Diseases Control and Prevention
(CDC) to get the percentage of death attributed Covid Vaccination in America. This was
used to approximate the risk of death in Cameroon because of the lack of data on the risk of
vaccination in Cameroon resulting from the low rate of vaccination in Cameroonians.
The number of cases, recoveries, and death of Covid patients were gotten from the daily
updates of the worldometer of the 24 of my ay 2021. Data on the current population of
Cameroon as of May 23, 2021, was equally gotten from worldometer 2021. Percentages, relative
risk ratios, and odds ratios were used for the analysis.
As of 25 May 2021, 0.27% of Cameroonians were infected with Covid while 0.25% of them had
recovered from the infection, 0.0046% had died. The results equally showed that 0.0017%
of deaths were attributed to Covid vaccination and 0.0046% deaths to Covid infection. The
relative risk and odds ratio comparing deaths from Covid vaccination and infection were 0.38
and 137 respectively. Both gures were far less than 1, thereby indicating that the risk and
odd of dying are by far lower among people vaccinated (cases) than amongst non-vaccinated
people(Control).
This study, therefore, led to the conclusion that the risk of dying from Covid-19 vaccination is
about 3 folds lower than dying from Covid infection especially amongst elderly people. This
work thus recommended massive covid vaccination especially for the elderly. The elderly were
found to more likely die from Covid 19 infection than the side effects.
Emily Callen, Theresa Li, Sarah Adler, Linda Chyr and , Johns Hopkins
University, Baltimore, MD
Most low- and middle-income countries (LMICs) have largely relied on the COVID-19 Vaccines
Global Access (COVAX) Facility to obtain sufcient doses to vaccinate up to 20% of their
populations. But evidence on the value and affordability of investing to expand COVID-19
vaccine coverage in LMICs is still lacking.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
To assess potential tradeoffs between the costs and benets of investing to increase COVID-19
vaccine coverage in Advance Market Commitment countries (AMCs) participating in COVAX.
A decision tree model with a one-year time horizon compared the standard of care (no
vaccination) to introducing the BNT162b2 (Pzer-BioNTech), mRNA-1273 (Moderna), JNJ-
78436735 (Johnson & Johnson’s Janssen), and ChAdOx1 (Oxford–AstraZeneca) vaccines,
standalone or in combination, under alternative coverage scenarios (20%-70% of the
population) within AMCs. For each vaccination strategy, the decision included no, partial, or
full vaccination. Individuals could subsequently become infected conditional on vaccination
status and vaccine efcacy. Infected individuals could either develop a mild disease that
resolves within days or become hospitalized. Hospitalized individuals could fully recover or die
of COVID-19. Country-specic costs included those related to vaccine procurement, storage
(including ultra-cold-chain costs) and distribution, and medical care. Effectiveness was
measured in fatalities and disability-adjusted life years (DALYs) averted. The incremental cost-
effectiveness ratio (ICER) was measured in cost per death or DALY averted and compared to
willingness-to-pay (WTP) threshold of US$50,000/DALY. Model parameters were derived from
the clinical, epidemiological, and economic literatures. Costs and effectiveness measures were
discounted at 3% annually. One-way and multivariate probabilistic sensitivity analyses were
conducted to assess the impacts of parameter uncertainties.
Preliminary results indicate that relative to no vaccination, all vaccination strategies are highly
cost-effective, costing US$200-$9000/DALYs averted. Increasing vaccine coverage is costlier
but produces more health benets, albeit with diminishing returns: the ICER with a coverage
level of 70% in all countries is approximately US$15000/DALYs averted. Results also suggest
that combination strategies are more cost-effective than single-vaccine strategies. Sensitivity
analyses suggest that vaccine cost-effectiveness prole improves with higher attack rates and
higher vaccine efcacy but deteriorates with lower vaccine acceptance and higher vaccination
costs.
Supporting and funding vaccination programs in LMICs is critical to containing the COVID-19
pandemic, globally. Our results suggest that expanding coverage is good value for money and
can advance this objective, as well as that of vaccine equity.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Martine Audibert2, Issaka Sagara3, Abdoulaye Djimdé3 and Ogobara K.
Doumbo4, (1)National Institute of Public Health, Bamako, Mali, (2)CNRS - CERDI Clermont-
ferrand (France), (3)Malaria Research and Training Center, University of Sciences, Techniques
and Technologiques de Bamako, Bamako, Mali, (4)Malaria Research and Training Center,
University of Sciences, Techniques and Technologiques de Bamako
The ndings of several research show that malaria has a negative impact on the standard
living of households, but few studies have looked at the immediate effect of malaria reduction
on household savings and investments in human capital. The aim of this study was to assess
the impact of malaria reduction through interventions during the period of high malaria
transmission that coincides with the start of the school year in Mali, on household savings and
investments in children’s education.
We conducted a randomized controlled trial consisting of four randomized groups of
households in a rural village of Mali (Birga): (i) Control group that received only seasonal malaria
chemoprevention (SMC) drugs, (ii) Full intervention group that, in addition to SMC, received
Insecticide treated nets (LLINs) and maternal Information on malaria prevention, (iii) SMC +
LLINs, and (iv) SMC + Information. We carried-out two surveys in July (pre-intervention period)
and December (post-intervention period) 2016 on the same samples to collect information
on household characteristics, education expenditures, bed net use, and medical data (clinical
examinations, malaria biological tests) among children under 5 years old. We used the
difference-in-difference methods to estimates the effects of our intervention by the intention-
to-treat (ITT) approach to draw accurate conclusions and local average treatment effect (LATE)
which using instrumental variable method to estimate the effect for the compliers.
The ITT estimates imply that, savings and education expenditures had increased by 3194 F
CFA (4.9 euros) and 2863 F CFA (4.4 euros) respectively among households in the intervention
group. Similar changes have found with LATE estimates, 1847 F CFA (2.8 euros) and 2137 F CFA
(3.3 euros) for savings and education expenditures respectively. While these effects were due to
an increase in bed net use (+28%) among children under 5 years of age, which led to a decrease
in clinical malaria prevalence (-9.1%) in ITT, the mechanism of transmission in LATE could not be
clearly demonstrated
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The ndings of our study contribute to the literature on the negative impact of malaria at the
micro level. Reducing the level of malaria allows households to save and invest in children’s
education. Although the results of this study imply that effective malaria control is associated
with a positive return on human capital, large-scale and long-term studies are needed to
better understand this issue.
1, Hannah Marker2, Mark McGovern3, Kassoum Kayentao4, Oumar Sangho4,
Hamadoun Sangho4, Peter Winch2, Joshua Yukich5 and Seydou Doumbia4, (1)National
Institute of Public Health (INSP) and University of Sciences, Techniques and Technologies
of Bamako (USTTB), Bamako, Mali, (2)Bloomberg School of Public Health, Johns Hopkins
University, Baltimore, MD, (3)Department of Biostatistics and Epidemiology, Rutgers School of
Public Health, Piscataway, (4)University of Sciences, Techniques and Technologies of Bamako
(USTTB), Bamako, Mali, (5)Tulane University, New Orleans, United-States
In 2017, malaria killed 435,000 people worldwide. $3 billion USD has been mobilized for its
control and elimination, at cost of $2.32 USD per person at risk.
Seasonal Malaria Chemoprevention (SMC) has been recommended since 2012 by WHO in
endemic areas and has only reached half of the children targeted. In Mali, from 2013 to 2017,
the SMC coverage rate increased from ve (19%) to all 65 districts (PNLP, 2018). The cost of
SMC per child was $ 0.6 to $ 4.03 USD in 2011 (White, 2011). This study aims to synthesize the
literature, presenting the costs, cost-effectiveness, or SMC economic studies.
The search was done using key words in electronic databases. Preliminary searches have been
conducted to identify key words and databases that will be used for the systematic review.
Screening was done independently by two researchers and consisted of a title and abstract
review to determine if the article meets the inclusion criteria. At this stage the data extraction
consisted of lling in the PRISMA ow diagram. A qualitative assessment of the extracted data
was carried out using the CHEERS checklist
For search, we used key words in the following databases: PubMed, Embase and CINAHL, 1517
publications were found. The articles were published between 1948 and 2021. The screening
allowed us to retain 37 publications that met the inclusion criteria and among which we
found the full text for 19. Many of those eliminated during the search full text were eliminated
because the abstract only had been published in a conference booklet.
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Conducting this systematic review is an attempt to produce a synthesis of the published
studies on cost and cost-effectiveness analyses of SMC worldwide. Limited number of
publications selected shows how important it is to conduct this research.
Cost, cost-effectiveness, Seasonal Malaria Chemoprevention, Systematic review,
Child health, Mali.
, Catholic University of Cameroon(CATUC)Bamenda, Department of
Health Economics Policy and Management, Bamenda, Cameroon, Dr. Kinga Bertila Mayin,
Catholic University of Cameroon(CATUC), Bamenda, Department of Health Economics, Policy
and Management, Bamenda, Cameroon and Njong Mom Aloysius, University of Bamenda,
Faculty of Economics and Management Sciences., Bambili, Cameroon
Even though Antiretroviral therapy (ART) services in Cameroon are highly subsidized, people
living with HIV/AIDS still incur a non-ART drug cost which places an economic burden on them
and their households and may hinder delivery and utilization of the subsidized services.
The primary objective was to assess the inpatient and outpatient costs incurred by people
living with HIV/AIDS and determine if the cost is a catastrophic burden to the individuals and
their households in Nkambe, Cameroon.
A single facility-based cross-sectional survey was conducted between February and June 2018
at Nkambe District Hospital, the North West region of Cameroon. A micro-costing analysis
was used to determine the direct and indirect cost of treatment and access, as well as the
catastrophic health expenditure. Data were collected using an administered questionnaire
and secondary data from patients’ les. These data were analyzed for the direct and indirect
cost of treatment of HIV/AIDS. The catastrophic health expenditure (CHE) was measured by
the number of participants whose monthly ART-related household expenditure for outpatient
and inpatient visits as a proportion of non-food expenditure was higher than 40%. The 40%
threshold has been used in various settings. A total of 348 participants were enrolled (283
outpatients and 65 inpatients).
The average direct cost of treatment access was 2108.89FCFA ($3.47) for outpatient and
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
30414.31FCFA ($54.12) for inpatient, giving an annual average cost of 8435.56FCFA ($15) and
121657.24 FCFA ($216.5), respectively. The cost of transportation to the hospital, as well as the
cost of non- ART drug services, was signicant for those from a rural location and the low-
income group. The incidence of CHE was 20.3% for outpatient and 66.7% for inpatient visits,
considering a 40% threshold. Factors that determine CHE identied were: use of motorbike
as a mode of transport, having a divorced marital status, borrowing and support from family
members. The most common coping strategies adopted by participants were increasing
working hours and support from friends and relatives. About half of the participants said these
strategies were sustainable.
Subsidization of ART services is not sufcient to eliminate the economic burden of treatment
on HIV patients. Implementing effective community dispensation of ARVs and universal health
coverage policy in Cameroon will go a long way to help HIV patients and their households.
, PATH, Seattle, WA
Ghana, Kenya, and Malawi started providing RTS,S/AS01 malaria vaccine in 2019 in selected
areas as part of the Malaria Vaccine Implementation Program (MVIP), a coordinated evaluation
led by the World Health Organization, with support from global partners. The four-dose
malaria vaccine is administered to children between the ages of 5 months and roughly 2 years
through the routine immunization system.
This study aims to generate estimates of incremental cost of introducing and delivering the
malaria vaccine within the routine immunization programs in sub-national areas of the malaria
vaccine pilot countries.
An activity based retrospective costing analysis was done from each government’s
perspectives. Detailed resource use data were extracted from expenditure and activity reports
for the period of 2019 and 2020. Primary data from representative health facilities were
collected to inform recurring operational and service delivery costs. Costs were categorized as
introduction and recurrent costs. The analysis considered a range assumed vaccine price ($2
to $10 per dose). Both nancial and economic costs were estimated and reported in 2020 USD
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
units.
Across the three countries, at a vaccine price of $5 per dose, the estimated incremental cost
per dose administered range from $2.46 to $3.18 (nancial), and $8.83 to $10.78 (economic).
The non-vaccine cost of delivery range between $1.20 and $2.50 (nancial) and $2.07 and $4.77
(economic). Considering only the recurring costs, the non-vaccine cost of delivery per dose
ranges between $0.40 and $1.10 (nancial) and $0.96 and $2.67 (economic). Introduction costs
constitute between 32% and 66% of the total nancial costs. Commodity and procurement add
on costs, which includes injection supplies and freight/insurance, were the main cost drivers of
total cost across countries.
The cost estimates generated from this analysis is useful to support country-level decisions
on the expanded use of the vaccine. Specically, it helps in understanding the feasibility of
implementing malaria vaccine, inform cost-effectiveness and budget impact analyses of
delivering the vaccine through the national immunization programs in respective countries.
Ranju Baral (rbaral@path.org) on behalf of the Malaria Vaccine
Implementation Program (MVIP) team including, PATH, WHO, GSK, and Ministries of Health in
Ghana, Kenya, and Malawi.
Obinna Onwujekwe, and Eric Obikeze, University of Nigeria, Nsukka,
Enugu Campus, Enugu, Nigeria
The prevalence of diabetes mellitus and hypertension is increasing yearly in low and middle-
income countries (LMIC) such as Nigeria. The increasing burden of these non-communicable
diseases has led to increase in overall cost of health care.
This study aimed at determining the direct and indirect healthcare cost of diabetes mellitus
and hypertension occurring both singly and in co-morbidity and their catastrophic health
expenditure in Southeast Nigeria.
The study is a hospital based quantitative, cross-sectional, descriptive study done among
patients attending the medical outpatient clinics of the Enugu State University Teaching
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Hospital, Parklane, (ESUTH) Enugu State, South-East Nigeria. A total of 817 patients were
randomly selected from the medical clinic of the hospital. Data was collected using a
pre- tested questionnaire. Average direct and indirect costs were estimated and level of
catastrophic health expenditure among the respondents were analyzed. Concentration index
was used to measure the level of equity in the distribution of the health outcomes.
Out of 817 patients interviewed, 37% had only diabetes mellitus, 35% had only hypertension
while 28% had both in co-morbidity. Direct costs of treating diabetes mellitus and hypertension
in the last one month before the survey were $28.40 and $19.35 respectively. Indirect costs
for diabetes mellitus and hypertension treatment in one month before the study were $7.36
and $5.51 respectively. Direct and indirect costs for diabetes mellitus and hypertension in
co-morbidity were $37.00 and $4.62 respectively. Concentration index showed that diabetes
mellitus and hypertension were more evident among the poor than the rich respondents
when examined singly, while it is more among the rich when examined in co-morbidity. The
catastrophic health expenditure at thresholds of 10%, 20% and 40% of their income were 81%,
54%, and 28% respectively in the last one month before the survey.
Burden of the hypertension and diabetes mellitus both singly and in comorbidity is high
amongst the respondents. Safety net information of health insurance is needed to cushion the
effects.
Non-communicable diseases, Direct and Indirect costs, Catastrophic health
expenditure.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Ronelle Burger1 and Dieter von Fintel2, (1)Department of Economics,
Stellenbosch University, Stellenbosch, South Africa, (2)Stellenbosch University Professor,
Stellenbosch, South Africa
Pregnant women and neonates are more vulnerable to malaria in developing countries. Given
frequent shortages of lifesaving drugs, they are burdened by adverse effects of malaria, such
as low birth weight and maternal anaemia. This paper investigates the effects of malaria
prophylaxis stock outs on health outcomes of pregnant women and their newborn babies
in Zimbabwe. To achieve the research objective, the paper used pseudo-panel data model
and the 2015 Demographic Health Survey and Ministry of Health and Child Care data on
malaria prophylaxis stock outs. The paper found that malaria prophylaxis stock outs occurred
frequently and affected the birthweight of babies in Zimbabwe. Therefore, policy makers
should invest in pharmaceutical information systems and stock ordering systems to prioritise
the prevention of malaria as proposed in the Sustainable Development Goals.
JEL Classication Codes: I10, I18, H57
, Makerere University School of Public Health, Kampala,
Uganda
Sub-Saharan Africa (SSA) has persistently contributed the largest share of global child
mortality of all ages. Most SSA countries are far from achieving the SDG’s target of reducing
under-ve and new-born mortality. To accelerate progress, we need to rethink of new
approaches and framework that can mitigate the already known mortality and morbidity risk
factors and mortality causes. In this study, I synthesise the recent study results from multiple
sources in Uganda to understand child mortality mechanisms and henceforth suggest an
alternative coherent approach that can be applied to improve new-born health and survival.
Using a decade (2005-2015) health and demographic surveillance data, I found that the
probability of a new-born child dying before reaching the age of 10 was 129 per 1000, and the
probability of the child aged 5 years dying before reaching the age of 10 was 11 per 1000.
Furthermore, the probability of a live birth dying before 28 days and ve years of age was
19 and 1000 per 1000 live births, respectively. Further analysis on the timing of new-born
deaths revealed a stagnation in perinatal and new-born mortality rate between 2011-2015.
The perinatal mortality stagnated at 32 per 1000 birth, with death within the rst day of life
stagnating at 26 per 1000 births. Similarly, new-born mortality reduced by 14% from 22 per 1000
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
in 2011 to 19 per 1000 live births in 2015.
The mortality risk factors for all ages and under-ve morbidity risk factors were the same.
These were adolescence age, poor wealth positions, low levels of education, rural residence,
low birth weight and multiple birth status. Low birth weight and prematurity, antepartum,
and intrapartum complications accounted for 94% of all causes of death among new-borns.
Malaria, malnutrition, acute respiratory and diarrhoea infection accounted for 88% of all causes
of death among children aged 0-5 years. Injuries and gastrointestinal diseases emerged
among the top four causes of death in the 5-9 age group, with malaria and malnutrition
remaining. 80% of women who experienced new-born mortality had experienced morbidity in
pregnancy.
The newborn and 0-3 years remain critical period for child morbidity and mortality. The
mortality and morbidity risk factors and mortality causes cannot be only addressed with
biomedical interventions. Moving beyond the health sector and the diseases and age-specic
interventions, there is a need for approaches that recognise life course and multisectoral
collaboration.
1, Noemi Kreif2, Peter C. Smith2, Gowokani Chirwa3 and Gerald Manthalu4, (1)
University of York, Addis Ababa, Ethiopia, (2)University of York, York, United Kingdom, (3)
Chancellor College, Zomba, Malawi, (4)Ministry of Health, Lilongwe, Malawi
Despite vast improvements in the past three decades, the global burden of mortality and
morbidity from childbirth remains exceptionally high. A vast majority of these deaths occur
in low- and middle-income countries and are considered preventable. Currently, 60 countries
are on course to miss their SDG targets for neonatal mortality by 2030. As most obstetric
complications occur around the time of delivery and cannot be predicted, it is generally
accepted that a key strategy to reducing pregnancy related mortality is to ensure women
deliver in health facilities under the supervision of trained health care professionals. A policy
proposal which has seen renewed emphasis to increase the utilisation of obstetric health care
services in the hope of improving maternal and neonatal health outcomes is the construction
of Maternity Waiting Homes.
We evaluate the impact of Maternity Waiting Homes on women’s utilisation of pre-natal,
post-natal and delivery health care services. Additionally, we examine whether there is any
discernible impact on maternal morbidity and neonatal mortality.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
We combine information on the construction of Maternity Waiting Homes at health facilities
with facility location data from the Service Provision Assessment and retrospective data
on births, birth outcomes and obstetric health care utilisation from the Demographic and
Health Survey. Our empirical strategy relies on exploiting differential timing in the opening of
Maternity Waiting Homes across Malawi. We implement new methods developed to analyse
treatment effects using a staggered difference-in-difference approach.
Our ndings suggest that Maternity Waiting Homes did not increase the rate of facility delivery
in Malawi between 2010-2016. Relatedly, there was no improvement in health outcomes for
mothers or new-borns. However, we do nd small effects for the utilisation of antenatal and
postnatal care. Our results are robust when examining women who reside furthest from health
facilities.
We suggest that in environments with pre-existing high rates of facility delivery, such as
Malawi, alternative policies to improve obstetric health outcomes may be more effective and
cost-effective. While we do not suggest that Maternity Waiting Homes are not a prudent
policy prescription in some environments, our ndings illustrate the issue with one-size-ts-all
policy adoption and the spread of popular generic policies without due consideration of their
appropriateness to specic settings.
, GCTU, Accra, Ghana
Ghana like many other Sub-Saharan African countries, encounters persistent maternal health
challenges, with very slow progress towards improved outcomes. Most of these challenges are
as a result of delayed or poor management of complications that come up during pregnancy,
delivery or the postnatal period. For this reason, investing into strategies to increase access to
care and the has been explained as a major step in improving overall postpartum outcomes.
In 2008, the government of Ghana instituted the Free Maternal Health Care Policy (FMHCP)
under the National Health Insurance Scheme (NHIS). The FMHCP was aimed at increasing and
improving access to maternal health services, by exempting pregnant women from paying the
insurance premium for the NHIS.
The aim of the study is to assess the effect of fee exemption policies on postpartum health
outcomes. The objectives of the paper are twofold. First, the study examines the effect of the
FMHCP on maternal postpartum outcomes. The study proceeds to assess the interaction
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
of selected socioeconomic variables with the FMHCP and the resulting effect of maternal
postpartum outcomes.
The logit regression model is one of the most effective tools adopted in examining the
relationship between the binary dependent variable and explanatory variables. The logit
model explicitly states the relationship between a binary dependent variable and a vector of
explanatory variables and predicts the logit of the dependent variables for the explanatory
variables. The study uses data from repeated cross-sectional data from the Ghana
Demographic and Health Survey. The specic rounds of the survey that were utilized were the
fourth and sixth rounds, collected in 2003 and 2014 respectively, with 2003 as the baseline.
The study showed that progress to reduce delivery and postpartum complications have
remained insignicant. Despite the operations of the FMHCP, there are some 21.42%
women who still deliver at home without skilled care, fueled by certain socioeconomic and
demographic characteristics. The outcome of this study reveals that, there is need for a
comprehensive and holistic maternal health interventions as factors that affect maternal
health are multifaceted. The ndings also bring to awareness the need to look beyond the
policy variable in health policy evaluations. There are many other variables that affect health
care utilization and health care habits that go beyond nancial demands.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Save the Children International, Kigali, Rwanda
Diabetes mellitus (DM) is a chronic disease characterized by high blood sugar levels due
to the body’s inability to produce enough energy and insulin, where a hormone is involved
in the metabolism from glucose input. In Africa, the last estimated $9.6 billion spent in
2019 was spent on caring for DM patients, among other NCDs, and spending on the same
chronic disease is likely to grow exponentially in the coming years. In Kenya, the total health
expenditure per capita is reported at around US$78.6, with health expenditures accounting for
about 4.5% of total government spending. The study aims to estimate the direct and indirect
costs of Diabetes mellitus in Kenya from a societal perspective, with 2019 as a reference year.
The cost of illness approach was used to estimate the economic burden of diabetes mellitus
in Kenya. The approach identies and measures all the costs of diabetes mellitus, including
direct and indirect costs. The full economic cost of DM illness was estimated for the year 2019.
In addition, a societal perspective was employed to include costs incurred by the country’s
Ministry of health, DM patients, and family members.
The 552,400 adult cases reported in 2019 resulted in a total economic cost of USD 372,184,585,
equivalent to USD 674 per DM patient. The total direct costs accounted the highest proportion
of the overall costs at 61% (USD 227,980,126), whereas indirect costs accounted for 39% of the
total economic costs (USD 144,204,459). Costs of medicines accounted for the largest costs
over the total economic costs at about 29%, followed by the income lost while seeking care
at 19.7%. Other costs that accounted for more than 10% of the total costs include productivity
losses (19%), diagnostic tests (13%), travel (12%). The rest of the cost categories accounted for less
than 5%. Efforts should be made to reduce the costs of these medicines to enhance care. The
high indirect costs reported, majorly in income lost by patients while seeking medical care, are
19%.
Despite data limitations, the estimates reported here demonstrate that DM imposes a
substantial economic burden on Kenya’s health care system, patients, and families. Access to
affordable health services such as DM education, regular blood glucose screening initiatives,
and increasing local manufacturing of medicines can reduce the economic burden of DM and
increase the health outcomes of the population and their contributions to society.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Nnamdi Ude1, Solumkenechukwu Ifeoma Onah1, Nwadiuto Ojeilo1 and
Udochukwu Ugochukwu Ogu2, (1)University of Nigeria, Enugu, Nigeria, (2)HPRG, Enugu,
Nigeria
Prior to the index case in 2019, there was no ofcial preparedness plan on ground and
inadequate public awareness on COVID-19 in Nigeria. Health system nancing and
infrastructural development was at a very low point This study aimed to nd out information
and determine capacity of the Nigerian health system responses to COVID-19 in the country.
A scoping review of media and ofcial documents and journals, published from 1st December
2019 to 31st December 2020 was done. Other online news sources that have consistently
reported health systems response to COVID-19 in Nigeria, were also reviewed. Geographical
scope of articles was national and sub-national. The search was conducted in English and
performed in PubMed, Google Scholar and Scopus.
Nigeria’s International Health Regulations (IHR) score at point of entry (PoE) 1 & 2 was 3 and 1
in 2019. Routine capacities established at points of entry was improved after the index case,
however, effective public health response at point of entry, remained the same. After the index
case, a presidential task force to organize response to the pandemic and oversee nationwide
lockdown measures was inaugurated. However this brought about poor access to food and
income by millions of Nigerians. Non health responses such as conditional cash transfers
and welfare packages were haphazardly done and deemed not to have met the adequate
economic response need.
By December 31st, 2020, Nigeria had 70 free laboratories from an initial 13 before the pandemic.
Available testing platforms were G-expert, open PCR, Corbas and Abott, with a capacity to
test 2500 samples a day, only half of this was achieved due to inadequate human resource
supply. Equipment, infrastructure and supplies received a boost after the index case but still
considered inadequate, as there were 350 intensive care unit (ICU) beds prior to index case, by
31stDecember there were 450 ventilated ICU beds. Local production and sourcing of materials
were encouraged though this remained below par at 14 mobile testing booths. Health worker
infection rose as shortage of PPE’s was cited as a cause.
Nigeria’s health system response and capacity to handle COVID-19 is quite poor and grossly
inadequate. There is a need to increase the number of health workforce in the country and
institute adequate accountability mechanisms to ensure prudent and focused management of
health funds.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Rahab Mbau2, Julie Jemutai3, Anita Njemo Musiega1, Kara Hanson4, Sassy
Molyneux3, Charles Normand5, Benjamin Tsofa3, Isabel W Maina6, Andrew Mulwa7 and Edwine
Barasa2, (1)Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme,
Nairobi, Kenya, (2)Kemri-Wellcome Trust Research Programme, (3)KEMRI-Wellcome Trust
Research Programme, Kili, Kenya, (4)London School of Hygiene and Tropical Medicine,
London, United Kingdom, (5)University of Dublin, (6)Ministry of Health, Nairobi, Kenya, (7)
Council of Governors
Efciency gains is a potential strategy to expand Kenya’s scal space for health. We explored
health sector stakeholders’ understanding of efciency and their perceptions of the factors
that inuence the efciency of county health systems in Kenya.
To understand the perceptions of health sector stakeholders on efciency and the factors that
inuence it as an initial step in efciency analysis.
We conducted a qualitative cross-sectional study and collected data using three focus group
discussions during a stakeholder engagement workshop. Workshop participants included
health sector stakeholders from the national ministry of health and 10 (out 47) county
health departments, and non-state actors in Kenya. A total of 25 health sector stakeholders
participated. We analysed data using a thematic approach.
Health sector stakeholders indicated the need for the outputs and outcomes of a health
system to be aligned to community health needs. They felt that both hardware aspects of
the system (such as the nancial resources, infrastructure, human resources for health) and
software aspects of the system (such as health sector policies, public nance management
systems, actor relationships) should be considered as inputs in the analysis of county health
system efciency. They also felt that while traditional indicators of health system performance
such as intervention coverage or outcomes for infectious diseases, and reproductive,
maternal, neonatal and child health are still relevant, emerging epidemiological trends such
as an increase in the burden of non-communicable diseases should also be considered. The
stakeholders identied public nance management, human resources for health, political
interests, corruption, management capacity, and poor coordination as factors that inuence
the efciency of county health systems.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
An in-depth examination of the factors that inuence the efciency of county health systems
could illuminate potential policy levers for generating efciency gains. Mixed methods
approaches could facilitate the study of both hardware and software factors that are
considered inputs, outputs or factors that inuence health system efciency. County health
system efciency in Kenya could be enhanced by improving the timeliness of nancial ows
to counties and health facilities, giving health facilities nancial autonomy, improving the
number, skill mix, and motivation of healthcare staff, managing political interests, enhancing
anticorruption strategies, strengthening management capacity and coordination in the health
sector.
, Centre for Health Economics, University of York, York, United Kingdom and
Martin Chalkley, Centre for Health Economics, University of York
Non-prot faith-based providers (FBPs) deliver 30-70% of all care in Sub-Saharan Africa
(SSA) and are often located in rural and remote areas where there are no other accessible
providers. FBPs differ from public providers as they usually charge user fees, are perceived to
provide higher quality of care and offer fewer reproductive services. Therefore, it is likely that
the ownership of accessible health facilities impacts the demand and utilisation of services.
Limited descriptive research on differences in healthcare management in SSA utilises data on
patients who present at the facility. It is unknown how the ownership of facilities affects the
demand for health services which may subsequently lead to health disparities.
The objectives of this study are to investigate how geographical access to different types
of ownership of health facilities impacts the use of services in Malawi. Specically, we are
interested in exploring heterogeneous effects of access to FBPs and public providers across
service domains and demographic groups. Such ndings will inform about inequalities in the
access to health care depending on the service environment.
We analyse the 2015-2016 Malawi Demographic and Health Survey (DHS) and the 2013-2014
Malawi Service Provision Assessment (MSPA). Geographical access is dened as the existence
of a MSPA facility within a predened radius of a DHS village using spatial matching. We
will use individual-level regression models to estimate the relationship between the access
to a facility by ownership, and the likelihood of reporting to have visited a faith-based or a
public provider for services such as new-born, maternal, child and reproductive health. We
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
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will also investigate the relationship between ownership and the frequency and continuity
of service use and perceived barriers to care. Heterogeneity analyses will investigate whether
marginalised groups, such as poor or unmarried women, are more or less likely to utilise
certain services by ownership.
Preliminary descriptive ndings suggest that fewer women seek family planning and
treatment for children’s diarrhoea and fever at nearby FBPs relative to nearby government
facilities. On the other hand, there is a higher demand for giving birth at nearby FBPs.
This study is the rst to present evidence on differences in the use of healthcare services by
the ownership of available providers in SSA. Such evidence will help to guide government
decisions regarding the need for supplementary public healthcare investment or ne-tuning
of public-private arrangements.
, University of Education, Winneba, Winneba, Ghana and Krystal Rampalli,
School of Public Health, University of South Carolina, South Carolina
Ghana has fairly liberal abortion law, implemented through comprehensive standards and
protocols. Yet, challenges around access and provision of safe second-trimester abortions,
within the context of the law still remain.
In this paper the authors explored the ethical dilemmas of accessing second-trimester
abortion services during COVID-19 pandemic in Ghana.
An interest-analysis of seeking and providing safe second-trimester abortion services during
the COVID-19 pandemic in Ghana was done. Using principles-based analysis of the Ghanaian
abortion law, four ethical dilemmas of seeking and providing safe second-trimester abortion
services within the context of the law during the pandemic in Ghana are examined: (1) Should
special facilities be designated for second-trimester abortions during a pandemic? (2) Should
a risk of COVID-19 be a basis for assessing second-trimester abortion in Ghana? (3) Should self-
managed abortions be legally accepted during the COVID-19 pandemic? (4) Should second-
trimester abortion seekers be denied access if not an emergency?
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Despite the liberal abortion laws in Ghana, abortion seekers and providers continue to
experience ethical conundrums alike as they try to maneuver between the abortion law,
personal values, and genuine concerns for seeking or providing induced abortion either on-
demand, medical or legal grounds even in the midst of the COVID-19 pandemic in Ghana.
Whereas abortion seekers act in desperation whilst seeking abortion services, the providers
make substantial effort to work within the connes of the laws although some are tempted to
slightly stretch the interpretation of the law in certain instances and to make such bending of
the law ethically justiable to themselves to benet from the crisis. Additionally, it was noted
that Ghana lacks research on demand and availability of second-trimester abortions during
pandemics to inform national abortion policy and program decisions.
Each of the key ndings outlined have ethical implications for safe abortion care in Ghana.
Hence, empirical research is required to further explore the demand for second-trimester
abortions and availability of providers for safe services during a pandemic to inform policy and
program decisions to avert unsafe abortion-related fatalities that may be emanating from the
ethical dilemmas of accessing second trimester abortion during the pandemic.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Osondu Ogbuoji The Center for Policy Impact in Global Health, Tolulope Tokunyori
Oladele, National Agency for the Control of AIDS, Abuja, Nigeria, Gilbert Kokwaro, Strathmore
University, Nairobi, NC, Kenya, Addis Kasahun Mulat, Kilimanjaro Trading and Consulting,
Addis Ababa, NC, Ethiopia, Wenhui Mao, The Center for Policy Impact in Global Health,
Durham, NC.
The COVID-19 pandemic has led to disruption of prevention and treatment services worldwide.
The direct impact of COVID-19 on health services include clinics and hospitals in many hard-hit
countries have been overwhelmed with patients with COVID-19. Second, COVID-19 mitigation
policies and patients’ fears of getting COVID-19 from health care settings affected service use.
For example, during the rst lockdown period in South Africa, there was a weekly decrease
of about 48% in TB Xpert testing volumes. Third, human and budgetary resources intended
for managing conditions such as TB and HIV have been redirected to COVID-19 testing and
treatment. Fourth, international travel restrictions and regional COVID-19 outbreaks led to
temporary interruptions in supply chains for drugs, vaccines, and other health commodities.
Fifth, the economic consequences of COVID-19 increased nancial barriers at the household
and national levels to maintain routine health services.
In the short term, health budgets have been threatened or reduced in a number of cases, but
the COVID-19 crisis also represents an opportunity to catalyze major long-term UHC nancing
reforms in many countries.
This panel aims to share ndings from multiple countries on the impact and response
of COVID-19. Our panelists are outstanding researchers and policy makers from different
countries with multiple disciplines. The rst two presentations will share evidence of the
impact of COVID-19 from three different perspectives: the rst presentation will focus COVID-19
impact on HIV nancing in Nigeria; the second presentation extended the impact to health
systems and lessons for future emergency preparedness in Kenya. Then the third presentation
focus on Ethiopia’s response to COVID-19 with an assessment on whether Ethiopia’s social
assistance were pro-poor. The last presentation will discuss countries’ readiness for the
COVID-19 vaccine. Results from a multi-country survey and two in-depth bottleneck analysis
on Sudan and Ghana will be shared. Discussants will further the discussion on scaling up
COVID-19 vaccine and preparedness for future pandemic.
This panel will contribute to the important discussions and propose recommendations on
(i) how to effectively deploy COVID-19 vaccines in Africa (ii) how to mobilize additional public
sector health nancing from external and domestic sources; and (iii) how to rapidly strengthen
countries’ health delivery systems.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Tolulope Tokunyori Oladele, National Agency for the Control of AIDS, Abuja, Nigeria
COVID-19, the most devastating pandemic since the 1918 inuenza pandemic, has had severe
health and economic impacts, including in Nigeria. Nigeria is experiencing ‘a twin shock’—a
COVID-19 pandemic shock and a separate, economic shock. Nigeria has the third largest
HIV epidemic worldwide yet these economic shocks will likely affect the nancing of many
different social sectors, including health.
A literature review and secondary data analysis has been performed to estimate the impact
of COVID-19 on HIV health nancing. With the global and national economic effects of
COVID-19, donor funding, domestic public nancing and private out-of-pocket spending
for HIV could all be under threat. In the short term, donors have responded to COVID-19 by
mobilising additional funding to respond to the pandemic, such as nancing COVID-19 vaccine
development efforts. However, in face of post-COVID-19 austerity, ODA could be one of the rst
spending items that get cut. We are also seeing existing ODA ows to HIV being redirected to
COVID-19. Meanwhile, with the shocks to the Nigerian economy, the government will struggle
to meet its commitments to fund the budgetary allocation to HIV. Private domestic funding for
HIV will probably also fall due to declining income and loss of jobs. Affected households may
be unable to afford the cost associated with seeking HIV care in health facilities.
A fall in funding for Nigeria’s HIV response would have short and long-term. Short term
impacts include the limited access to drugs and loss to follow-up. And in long term, with stock-
outs and loss to follow-up, adherence is compromised and drug resistance may develop.
Given the risks of HIV resurgence because of the COVID-19 crisis, bold proactive steps are
needed, such as integrating HIV into the National Health Insurance Scheme, locking in donor
commitments to HIV and building a robust health system.
Gilbert Kokwaro, Strathmore University, Nairobi, NC, Kenya
Kenya reported its rst case of COVID-19 on 12th March 2020. Over the course of the COVID-19
pandemic, the Kenyan government has responded through various health and non-health
strategies to mitigate the impact of the pandemic on its population. This study aimed to
understand the key measures adopted in Kenya to tackle the COVID-19 pandemic, understand
how the pandemic impacted the health sector and the population more broadly, and how
future policy priorities and health emergency preparedness can be strengthened through the
lessons learnt from the COVID-19 pandemic response.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
We conducted semi-structured interviews using purposive sampling to identify in-country
stakeholders involved in the COVID-19 response and with a rm understanding of how the
pandemic affected the Kenyan healthcare system. 15 key informant interviews were conducted
between September 2020 – February 2021 with national and regional government ofcials,
development partners, non-government and civil society organization representatives, and
healthcare professionals. A deductive approach was used to analyze and code the interview
data using NVivo software.
The initial prompt response of the Kenyan government to introduce measures to curb the
pandemic, proactively share information and raise awareness was noted by most respondents.
However, there were shortcomings in managing effective provision for testing, isolation, and
quarantine services. Health services were negatively impacted due to overwhelmed health
facilities and personnel, which affected continuity of essential, routine and non-essential
health services due to reallocation of resources and facilities to cater to rising COVID-19 cases.
Respondents also highlighted that vulnerable groups, especially poor families in informal
settlements, women, and disabled persons were disproportionately affected by the lockdowns
and curfews imposed to curb the pandemic. Respondents further discussed overall resources
constraints, lack of personnel and supplies, along with coordination issues between national
and county governments.
Respondents also highlighted opportunities to improve future pandemic preparedness and
health system strengthening. Respondents suggested the need to create an emergency
fund within the Ministry of Health to minimize nancial shocks and access to funding during
future health emergencies. They also called for reforming the public nancial management
laws to allow exibility and improved facilitation and fund utilization both at the national and
county level. Additionally, respondents recommended greater multi-sectoral collaboration,
investments in health information systems and human resources for sustainable expansion of
capacity to respond to future health emergencies.
Addis Kasahun Mulat, Kilimanjaro Trading and Consulting, Addis Ababa, NC, Ethiopia
Ethiopia, the most populous country in Africa, experience high burden from COVID-19 and
75% of the households reported a reduction or total loss of income due to COVID-19. We aim to
assess whether Ethiopia’s social assistance measures were pro-poor.
We used time-to-event data collected through High-Frequency Phone surveys on COVID-19
and pre-pandemic data on household socio-demographic characteristics from Ethiopia Socio-
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Economic Survey (2018-19) for this analysis. We employed a semi-parametric Cox proportional
model to analyze time-to-event data and evaluate whether the time to receive government
assistance during the COVID-19 response of 2020 differed between poor and non-poor
Ethiopian households.
We included 3247 households for analysis. A third of these households were located in the
urban areas, around a fourth were female-headed, and nearly half of the households had a
household head with no prior schooling. Around 14.0% of households in Ethiopia received
some form of government assistance at least once by January 2021, within ten months from
the start of the COVID-19 pandemic. In this ten-month timeframe, government assistance
had reached a higher proportion of poor households (18.8%) than non-poor households
(10.6%). Similarly, the Ethiopian government reached a higher proportion of other vulnerable
households by January 2021. For example, 16.9% of rural households, 23.8% of female-headed
households, and 15.9% of households with uneducated heads received government assistance
vis-a-vis 9.9% of households in urban areas, 10.8% of with male-headed households, and 11.1% of
households with educated heads.
The Kaplan-Meier failure function for poor and non-poor households indicates that the
probability of receiving the rst government assistance was higher for poor households than
non-poor households between March 2020 and January 2021. Even after holding all other
variables constant, the expected hazard from the Cox PH regression was 1.71 times higher in
poor households than in non-poor households. In other words, poor households were 71%
more likely to receive the rst government assistance than non-poor households at any point
in time in ten months after the start of the pandemic.
In a public health emergency, government assistance is crucial to cushion vulnerable
households from health, food, and income shocks. However, government assistance is effective
only when it reaches the most vulnerable people on time. We found that the government
social assistance in Ethiopia was pro-poor in assisting.
Wenhui Mao, The Center for Policy Impact in Global Health, Durham, NC
With the development of effective COVID-19 vaccines, there is a need to ensure that these
vaccines are successfully administered to end the global pandemic. Many low- and middle-
income countries (LMICs) face nancial and logistical challenges to rolling out COVID-19
vaccines. We aim to assess vaccine delivery preparedness and identify challenges impeding
vaccine scale-up.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
A cross-sectional Qualtrics survey was developed with ve modules: (i) vaccine planning; (ii)
population prioritization; (iii) nancing and procurement; (iv) vaccine administration and
delivery; and (v) vaccine uptake. The survey was rolled out between January-June, 2021 across
LMIC stakeholders actively involved in the country’s COVID-19 vaccine planning and delivery,
including government ofcials, development partners, implementing agencies, experts, and
academics. Bottleneck analysis was assessed on vaccine manufacture or procurement, supply
and cold chain, providers that give vaccines and vaccine hesitancy based on publicly available
data for Ghana and Sudan.
A total of 48 survey responses were received from 28 countries: 19 from Sub-Saharan African
(SSA), 9 each from Central and South Asia, and Latin America & the Caribbean (LAC), 6 from
North Africa and West Asia, and 5 from East and Southeast Asia region. All countries reported
having vaccine taskforce and regulatory authorities in place for planning and implementation.
Respondents from East and Southeast Asia reported high levels of overall preparedness
for vaccine delivery, while respondents from SSA and LAC reported lower levels of overall
preparedness. The biggest challenges for vaccine scale-up cited by respondents from SSA
and LAC were geographic access to remote populations, supply chain, cold storage, and cost
barriers. Most SSA countries reported major nancing shortfalls despite planned budgetary
provisions and relying heavily on COVAX for procurement. Countries reported using mixed
procurement arrangements with 50% of SSA and LAC countries using UNICEF and regional
pooled procurement, along with self-procurement. For both Ghana and Sudan, the primary
bottleneck in scaling up COVID-19 vaccine is the procurement of COVID-19 vaccine, followed by
vaccine hesitancy. Positive lessons include Ghana’s employment of drone in deploying vaccine
and Sudan’s deep engagement with UNICEF in the vaccine delivery.
Our survey identied capacity constraints, especially in nancing and procurement of
COVID-19 vaccines. Supporting the COVAX facility and providing external nancing and
technical assistance to LMICs can help to ensure equitable access to COVID-19 vaccines.
Longer-term investments in procurement systems, nancing capacity, and delivery will help
strengthen overall health systems.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Cheryl Cashin Results for Development, Uju Onyes Health Systems Strengthening/
Health Financing Consultant, Cheickna Touré, Results for Development (R4D), Bamako, Mali,
Oludare Bodunrin, Strategic Purchasing Africa Resource Center (SPARC), Nairobi, Kenya, Dr.
Kélath Bello, MD, MPH, PhD Student, Centre de Recherche en Reproduction Humaine et en
Démographie (CERRHUD), Cotonou, Benin.
There have been many calls over the years to reimagine traditional technical assistance and
nd better ways to support country-led change. This impetus to support country-driven
change has galvanized a global community of stakeholders, committed to improving how
technical support for health systems strengthening is provided, to build the Coaching
Approach. The Coaching Approach draws mainly on country and regional experts to support
country change processes, supported by global coaches and mentors as needed. Working
through existing systems and processes, coaches bring technical expertise and evidence
adapted to suit particular country contexts, and they help facilitate more robust, country-led
processes through learning-by-doing.
This approach requires strong skills in stakeholder engagement, process facilitation,
knowledge translation and communication, in addition to technical expertise. In order help
health systems strengthening experts build and rene these skills, Results for Development
(R4D) and its partners have, over the past year, launched a three-module e-learning series. The
three e-learning modules include:
1. Introduction to the Coaching Approach, which details what it means to be a coach or a
mentor and how those in this role can help strengthen country processes and build lasting
capacity;
2. Designing and Facilitating Effective Processes which focuses on both the “how” and
importance of process facilitation; and
3. Remote Coaching, which highlights the skills required to provide technical support and
facilitation remotely.
In addition to building the sorts of skills featured in the e-learning modules, The Coaching
Approach seeks to put country expertise at the center of health system strengthening efforts
in low- and middle-income countries. In response to this ambition, we developed the Experts
Database, a repository seeking to elevate the proles of health systems experts in countries
requesting technical support. This database works to connect practitioners and policymakers
with local and global health experts and organizations to support health systems change.
R4D proposes a 90-minute session led by experienced coaches and mentors, who have co-
developed the coaching approach, to share experiences and introduce the resources available
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
to adopt and apply this approach. These coaches will also promote continued, joint learning
among this community of experts through a small group experience-sharing exercise. This
session will be in English, with simultaneous French translation provided.
Cheickna Touré, Results for Development (R4D), Bamako, Mali
In this session, we will provide a primer on the Coaching Approach, a way of providing technical
support that moves beyond traditional technical assistance in two important ways:
Who provides the support? The coaching approach draws mainly on country and regional
experts who can be supported by global coaches and mentors as needed.
How the support is provided. Support in the coaching approach connects to, respects, and
helps to improve upon existing country processes for decision-making, policy implementation
and execution of day-to-day functions.
Coaches and mentors are not the doers of work — they are not invited in to produce static
outputs like presentations and reports for countries. Rather, coaches and mentors guide
countries as they work through their own health systems challenges. They can serve as a
sounding board for ideas and help ask tough questions. Instead of telling countries what to
do (or what not to do), they share contextualized insights based on their own knowledge and
experiences. Coaches help countries focus on the how of achieving a successful outcome and
have the humility to know they do not have the “right” answers.
A coach or mentor may provide support to the design of the process, and they may support
countries as they go through some of these steps or the entire process. Coaches and mentors
make sure evidence and technical knowledge are brought into the process in a contextualized
and appropriate way that is adapted and usable. They also make sure that the capacity of
country partners is strengthened to carry out the activity on their own next time—this includes
making sure that systems are in place to institutionalize or reproduce the process.
Oludare Bodunrin, Strategic Purchasing Africa Resource Center (SPARC), Nairobi, Kenya
Coaches can play different roles as they support country partners—sometimes as a technical
resource person, and sometimes as a process facilitator, guiding the overall process of solving
the health system challenge, and bringing in additional coaches and mentors for specic
technical issues. In this session, we will look at how effective facilitators can add value and
help to improve country processes to more effectively engage the right stakeholders, bring in
evidence that is relevant and contextualized, and transparently build toward solutions that are
technically valid, feasible in the current context, and have buy-in and ownership of those who
will be part of implementing them.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
When countries are faced with a health system challenge, they typically go through a series
of similar steps to resolve the challenge, regardless of the technical area. First, a problem or
challenge or other need for change is identied. Challenges can be surfaced in many ways,
such as through routine monitoring, stakeholder voices, or sometimes political pressure. The
second step is examining evidence to better understand the problem and identify options
for solutions. The solution is then selected from among different options. Once a solution has
been identied — whether it is a policy, intervention, or some other solution — it needs to be
designed and then implemented. And nally, there is some type of monitoring, evaluation and
learning from implementation.
Process facilitation can add value throughout these steps. A facilitator can act as a legitimate
broker to guide the process through consistent engagement with the stakeholder group
over the period of time needed for a process to reach decisions and design and implement
solutions.
Dr. Kélath Bello, MD, MPH, PhD Student, Centre de Recherche en Reproduction Humaine et
en Démographie (CERRHUD), Cotonou, Benin
In this session, we will provide an overview of remote coaching, an approach to providing
technical support to a change process through virtual engagements. A fully remote or hybrid
(virtual + in-person) coaching engagement can be designed to support a local change process.
In these situations, there is likely some in-person interaction happening locally, but the coach
is not co-located and is providing some or all coaching through virtual means. During the
COVID-19 pandemic, most forms of technical support have needed to be delivered remotely.
However, even after the pandemic, remote coaching skills will still prove helpful when
designing and implementing a hybrid engagement.
When the coach is unable to be physically present, he or she can still support a country
change process through virtual process facilitation using a mix of online meetings, virtual
consultations, and e-communications.
A remote coach needs to:
• Remotely support the key counterpart(s) to design the coaching process with virtual
engagements in mind
• Virtually collaborate to provide technical inputs for the process and co-produce outputs of
the process
• Participate remotely in meetings and facilitate virtual discussions at key points in the
process
• Identify other technical experts and facilitate their virtual engagements at the right points
in the process
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Designing and facilitating effective remote coaching engagements requires skills to:
• Build trusting relationships through remote interactions, keeping in touch through regular
virtual check-ins, phone calls, and e-communications
• Design and facilitate different interactive formats such as virtual working group meetings,
remote briengs, and virtual workshops, with a mix of dialogue and information sharing.
• Facilitate virtual feedback loops to continuously adapt and improve your coaching support
and keep everyone motivated.
Success of remote coaching can be measured at individual, group, and systems-levels,
ultimately contributing to improvements in health, education, and nutrition outcomes.
for collecting participant feedback include:
Post-event feedback (e.g., virtual survey or brief poll) at the conclusion of a virtual meeting or
event
Virtual checkpoints (one-on-one outreach calls or emails, “pause and reect” meetings) with
country partners to solicit feedback at key moments in the process
Post engagement follow-up with country partners (e.g., one-on-one outreach and/or a brief
online survey) 3-6 months after the conclusion of the engagement to assess how the change
process has progressed and the impact it has had.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Simon Walker2, Freddie Ssengooba3, Elizabeth Ekirapa Kiracho3, Chrispus
Mayora3, Aloysius Ssennyonjo3, Candia Tom Aliti4 and Paul Revill5, (1)Center for Health
Economics, University of York, York, United Kingdom, (2)University of York, United Kingdom, (3)
School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda,
(4)Ministry of Health, Government of Uganda, Kampala, Uganda, (5)Centre for Health
Economics, University of York, York, United Kingdom
Health Benets Packages (HBPs) are a key tool in the path towards universal health coverage
(UHC). Methods for developing a list of interventions for inclusion into the HBP have typically
used standard cost-effectiveness analysis (CEA) methods based on maximising health subject
to an overall nancial constraint. In reality, at least in the short run, there are many other
constraints which limit the healthcare system’s ability to provide care. Explicitly factoring in
these constraints results in an HBP that can be implemented given health system capabilities
and allows for the exploration of the value of investing to expand constrained resources.
This study uses a linear constrained optimisation approach. 128 interventions across 10 disease
programs are considered with data on DALYs averted, full intervention cost, consumable cost,
health worker time requirement by cadre, and maximum feasible coverage of interventions
compiled using published literature and government documents. The objective of the
approach is to nd the optimal set of interventions to maximise the net disability-adjusted
life years (DALYs) averted, i.e. total DALYs averted by an intervention less its cost divided by the
marginal productivity of the health system. This is subject to three categories of health system
constraints - i. the budget for purchasing consumables, ii. the size of the health workforce
(by cadre), iii. the maximum feasible coverage level for each intervention (based on other
demand and supply-side constraints). We further use the approach to calculate the marginal
value of investing additional resources towards purchasing consumables or hiring additional
health worker time.
Out of the 128 interventions analyzed, 68 interventions were included in the optimal HBP for
Uganda, resulting in total of 53.8 million net DALYs averted. Further, investing only $39 towards
hiring additional nutrition ofcers’ time could avert an additional net DALY; this increased to
$55, $56, and $123 for nurses, pharmacists and doctors, and $971 for expanding the consumable
budget.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The public health system of Uganda can avert a total of 53.8 million DALYs, net of opportunity
costs by implementing the proposed HBP. In terms of the marginal value of additional
resources in the health system, investing in health workers generates much higher returns
than investing in consumables.
, University of Witwatersrand, Braamfontein, South Africa
Zambia is in the process of implementing a National Social Health Insurance Scheme
to achieve the goal of universal health coverage. This paper investigates socioeconomic
inequalities in household willingness to pay for National Social Health Insurance.
The paper used data from the representative Zambia Household Health Expenditure and
Utilization Survey. Contingent Valuation was used to elicit willingness to pay using a bidding
game technique. Interval, Tobit, Heckman and logistic regressions models were used to
examine the relationship between the ability to pay and willingness to pay. Concentration
indices and curves were used to measure inequalities in willingness to pay, while non-linear
Oaxaca-Blinder and Wagstaff decompositions were used to identify the factors that contribute
to these inequalities.
More than 80% of Zambians were willing to pay for National Social Health Insurance for their
households, which came to an average of K90.76 ($4.31) per month per household. Interval,
Tobit and Logistic regressions identied a positive correlation between the ability to pay and
willingness to pay. The concentration indices for socioeconomic inequalities in willingness to
pay were estimated at 0.389 for the absolute outcome variable and 0.196 for the dichotomous
outcome variable. In the non-linear Oaxaca-Blinder decompositions, the most important
factors that explain the willingness to pay gap were location (20%) and marital status (-5%).
The Wagstaff decomposition results suggest that monthly household expenditure (92%) and
access to health insurance (-8%) make large contributions to the inequalities in willingness to
pay.
The results of this paper imply that the contributions to the National Social Health Insurance
Scheme by households need to be adjusted for the ability to pay. Thus, to make the scheme
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
affordable, the government should consider a policy of varying contributions according
to the ability to pay in addition to exemptions and subsidies. Furthermore, policymakers
should target programmes that increase households access to health insurance and create
employment and income-generating activities that absorb everyone regardless of their
socioeconomic status.
, University of Dschang, Bujumbura, Burundi and Pierre Nguimkeu, Georgia State
University, Atlanta, GA
Paying-for-Performance (PfP) is a purchasing instrument which involves nancial incentives
being rewarded to health workers and/or facilities for reaching pre-specied performance
measures or targets related to quality and quantity of health services. Performance
measurement are made frequently by third-party entities measuring quantity and quality
in separate streams. PfP has been extensively analyzed to demonstrate impact on a variety
of horizontal care such as maternal, newborn and child healthcare, but almost no ndings
are reported on what could be the impact (conceptual, operational and on results) of the
purchasing mechanism on a vertical program.
The aim and objective of this paper is to assess the incremental impact PfP may have on a
HIV/AIDS vertical program in Mozambique. Some other horizontal services are included in this
assessment to test if the impact on the vertical program, if any, would deter impact on other
services. The paper disaggregates the results according the level of development of targeted
provinces to better discuss their heterogeneity.
The paper has used analysis of a quasi-experimental impact assessment using propensity
score matching associated with difference-in-difference regressions on health facility-based
routine data in southern and northern provinces in Mozambique. Data pertained to HIV/
AIDS-related health outcomes and health service utilization indicators; and to Reproductive,
Maternal, and Child Health and Nutrition indicators. Analyses were further improved in their
technical specications of indicators and geographical display to elicit better analyses and
discussions of the heterogeneity of the ndings.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The results show that PfP can lead to incremental impact on a vertical program, with even
more relative effect in less developed settings. Besides, they suggest that PfP can instill a more
purposive denition of indicators with improved quality content and outcomes. In addition,
with PfP nancing as an increment to a vertical program, the health system can leverage on
other non-vertical program indicators (and dimension) to improve HIV/AIDS service utilization
and vice-versa. Ultimately, unlike in most settings in developing countries where there are
separate streams for PfP volume verication and quality assessment, the ndings suggest
that, for operational efciency, services targeted with PfP in a vertical program can be dened
directly with enough quality content and be assessed in a single stream.
, Stellenbosch University, Stellenbosch, South Africa
Adverse health events can be expensive and unaffordable with catastrophic nancial and
welfare implications. Health insurance provides a form of nancial protection against future
unpredictable healthcare expenditure. Insurance companies operate through the principle of
risk pooling where healthier members (who claim less than they contribute) subsidise sicker
members (who claim more than they contribute). The notion of risk pooling in a voluntary
insurance market creates a conducive environment for adverse selection to exist.
In South Africa, health insurance (termed medical schemes) membership is voluntary, but
in most cases a necessity to access private healthcare. Insurers must follow open enrolment
and community rating requirements meaning they cannot deny applicants membership or
differ their premiums based on the individual’s age and health status. Understanding people’s
insurance purchasing behaviour is necessary as the country moves towards a National Health
Insurance.
Examine whether an increase in anticipated need for healthcare and therefore higher
healthcare expenses will drive people to purchase health insurance. We consider the effects of
individuals’ characteristics on their propensity to insure through using cross section analysis
and panel data.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
We use the National Income Dynamics Survey data sets. The analysis focuses on respondents
from the last wave who experience adverse health shocks such as being diagnosed with
a chronic condition(s) as well as their self-assessed health status. We include pregnancy/
births and biomarkers like BMI and blood pressure. Typical explanatory variables like income,
education, age and risk appetite are also factored into the analysis. The dynamic panel level
analysis over the last three waves (excluded time invariant variables) and focuses on health
indicators and changes over time. It includes two lagged variables (perceived health and
chronic health)
In the cross-section analysis, statistically signicant variables are income, population group,
marital status, education and formal sector employment. The signicant health indicator
is chronic conditions. In the xed effects panel analysis pregnancy was signicant, but
both lagged variables were insignicant, although chronic conditions without the lag were
signicant.
There may be some adverse selection built into the South African health insurance market,
but socio-economic factors appear to be major contributing factors to individuals’ insurance
purchasing decisions. Pregnancy being signicant in the panel analysis may be because health
insurers must cover all pregnancies in full.
, Department of Health Services, Policy, Planning, Management and
Economics, School of Public Health, University for Development Studies, Tamale, Ghana
Reforming healthcare provider payment mechanisms to incentivize healthcare providers is
essential for ensuring quality healthcare delivery during the COVID-19 pandemic. Capitation
as a provider payment mechanism gained policy attention by the Ghana National Health
Insurance Scheme (NHIS) and was piloted in the Ashanti Region between 2012 and 2017.
Recent studies revealed that the implementation of the policy was suspended due to
inappropriate framing of the policy in policy communications, actor contestations, challenges
with certain design provisions of the policy, and a loss of political support following a change
in government. Despite the suspension of the policy, capitation remains a provider payment
reform option under consideration by the NHIS.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Using the Geneau et al. (2010)’s policy analytical framework, the study assessed what is
required to regain policy attention for the re-implementation of the Ghana NHIS capitation
policy. The study specically explored how to: i) appropriately reframe the policy; ii) create
political opportunities; and iii) mobilize resources for policy re-implementation.
A qualitative prospective policy analysis was implemented in the Ashanti region of Ghana in
December, 2019. Data was gathered from media reports and semi-structured interviews with
a purposive sample of 19 regional, district and facility level policy implementers. The face-to-
face interviews were tape-recorded and transcribed. Thematic analysis of data was done using
NVivo 12 software.
In terms of reframing, stakeholders argued that the name capitation should be replaced with
a different name and public communication on the rationale for capitation should be shifted
from the cost containment frame to its health benets frame. Policy education should also be
rened to reect clarity in policy provisions for emergency care, capitation rates, and procedure
for choice of providers. Furthermore, stakeholders opined that to create political opportunities
for policy re-implementation, a politically sensitive approach with broader stakeholder
consultations and involvement should be adopted, and that policy communication should
be evidenced-based and led by politically neutral agents. Finally, the study revealed the
need to improve the service delivery capacities of health facilities, especially the lower-
level facilities, by resourcing them with improved infrastructure, consumables, improved
information management systems and well-trained personnel as a pre-requisite for policy re-
implementation.
The study calls for an effective reframing, creation of political opportunities, and mobilization
of needed resources to reattract policy attention to the capitation payment policy in Ghana.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Yukichi Mano2, Bocar Daff3, Serigne Diouf3, Khadidiatou Fall Dia3, Laetitia
Duval4, Josselin Thuilliez4 and Ryota Nakamura1, (1)Research Center for Health Policy and
Economics, Hitotsubashi University, Kunitachi, Japan, (2)Graduate School of Economics,
Hitotsubashi University, Kunitachi, Japan, (3)Agence de la Couverture Maladie Universelle,
Dakar, Senegal, (4)Centre d’Économie de la Sorbonne, UMR 8174 - CNRS, Université Paris 1
Panthéon-Sorbonne, Paris, France
Community-based health insurance (CBHI) has been implemented in many sub-Saharan
African countries as a strategy to increase nancial risk protection in populations without
access to formal health insurance. While the design of such social programs is fundamental
to ensure equitable access to care, little is known about the operational and structural factors
inuencing enrolment in CBHI schemes. In this study, we took advantage of newly established
data monitoring requirements in Senegal to explore the association between the operational
capacity and structure of CBHI schemes – also termed ‘mutual health organizations’ (MHO) in
Francophone countries – and their levels of enrolment.
We used novel nationwide administrative panel data collated by the National Agency for
Universal Health Financial Protection of Senegal to investigate the association between the
performance of the national CBHI scheme and a set of operational and structural factors at
the MHO level. The dataset comprised 12 waves of quarterly data over the period 2017-2019
and covered all 676 MHOs registered in the country. Primary analyses were conducted using
dynamic panel data regression analysis.
We found that higher operational capacity signicantly predicted higher performance:
enrolment was positively associated with the presence of a salaried manager at the MHO level
(12% more total enrollees, 23% more poor members) and with stronger partnerships between
MHOs and local health posts (for each additional contract signed, total enrollees and poor
members increased by 7%, and 5%, respectively). However, higher operational capacity was
only modestly associated with higher sustainability proxied by the rates of enrollees up to
date in their premium fees. We also found that structural factors were inuential, with MHOs
located within a health facility enrolling fewer poor members (-16%). Sensitivity analyses
showed that these associations were robust. No signicant heterogeneous effects were found
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
based on a range of demographic, socioeconomic, and health-related characteristics.
Our ndings suggest that policies aimed at professionalising and reinforcing the operational
capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most
impoverished populations. However, they also suggest that increasing operational capacity
alone may be insufcient to make CBHI schemes sustainable over time.
, Department of Economics, Kwame Nkrumah University of Science and
Technology, Kumasi, Ghana
The National Health Insurance Scheme (NHIS), operated by the National Health Insurance
Authority (NHIA) was introduced in Ghana in 2003 to provide nancial protection to the
population for healthcare utilization. There has been a signicant increase healthcare
utilization since the introduction of the scheme. This makes the scheme an important tool
for the achievement of universal health coverage. However, the scheme is facing nancial
challenges, with the cost of claims rising at a high rate. The NHIA has therefore introduced
electronic claims processing to improve the efciency in claims processing.
The aim of this research is to nd the efciency gains of the electronic claims processing
method in terms of resource use.
The study used claims data from the NHIA for both paper based and electronic claims
processing. Additional data on resource use was also included. The data analysis involved the
computation of adjustment rates for selected health facilities before and after the introduction
of electronic claims. Resource input mainly analysed was labour hours.
The results showed that adjustment rates increased with electronic claims. Please I need to
supress the results pending NHIA’s approval. I will be happy to share when the approval comes.
Thanks
A shift to electronic system improves the quality of claims processing. Please I have to supress
the rest. Thank you.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Richmond Owusu2, Dakota Pritchard1, Godwin Gulbi2, Lieke Heupink1, Katrine
Frønsdal1, Ivy Amankwah3, Francis Ruiz4, Mohamed Gad4, Brian Asare5, Joycelyn Naa Korkoi
Azeez3 and Justice Nonvignon2, (1)Norwegian Institute of Public Health, Oslo, Norway, (2)
Department of Health Policy, Planning and Management, School of Public Health, University
of Ghana, Legon, Ghana, (3)Ministry of Health, Ghana, Accra, Ghana, (4)London School of
Hygiene & Tropical Medicine, London, United Kingdom, (5)Ministry of Health, Accra, Ghana
Every year, there are more than 1,300 new cases of childhood cancer in Ghana, approximately
two-thirds of which are Burkitt lymphoma (BL). Close to 50% of children affected with BL die,
as a result of delayed care seeking and treatment abandonment. The nancial burden of care
seeking is often the main reason for treatment delay and abandonment. Yet childhood cancer
is not covered by the National Health Insurance service (NHIS). In this study, we analyze the
nancial and economic impact of extending health insurance coverage to children with BL in
Ghana. This study was part of a health technology assessment evaluating the management of
childhood cancer in Ghana, conducted by the Ministry of Health.
We developed a Markov model in Microsoft Excel to estimate the costs and effects of BL
treatment when NHIS was provided compared to the status quo where NHIS does not cover
care for childhood cancer. A cost-effectiveness analysis (CEA) was undertaken from the societal
perspective; and in addition, a budget impact analysis (BIA) taking the perspective of the
NHIS. The time horizon for the CEA was a lifetime and, the BIA was estimated over a ve-year
period. Both costs (US$) and effects, measured using disability adjusted life years (DALYs), were
discounted at a rate of 3%. Probabilistic sensitivity analysis was done to assess uncertainty in
the measurement of the incremental cost-effectiveness ratio (ICER).
In the base-case analysis, the intervention (NHIS reimbursed treatment) was less costly
than current practice (US$8,302 vs US$9,558). The intervention was also more effective with
less DALYs per patient than the standard of care (17.6 vs 23.33), with an ICER of US$219. The
probabilistic sensitivity analysis showed that the intervention is likely to be both less costly and
more effective than current practice in 100% of the 1,000 simulations undertaken.
Providing health insurance coverage to paediatric patients with BL is potentially highly cost-
effective. The effectiveness and cost-saving of this strategy is driven by its positive impact on
treatment initiation and retention. Based on this evidence, Ghana should consider prioritizing
funding for cancer treatment in children.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Sulaiman Saidu Bashir2, Zubaida Hassan3, Paul Sale Margwa2
and Esly Emmanuel4, (1)Federal College of Education Yola, Nigeria, (2)Adamawa State Primary
Health Care Development Agency, Yola, Nigeria, (3)Department of Microbiology Modibbo
Adama University, Yola, Nigeria, (4)Adamawa State Rural Water Supply and Sanitation
Agency, Yola, Nigeria
Social protection is a recognised strategy for poverty reduction, as articulated in the
Sustainable Development Goals (SDGs 1, 3, 5, 8 and 10), with a proven role of supporting
children and families. Social protection helps connect families with healthcare, nutritious
food and quality education to a targeted group of people. The COVID-19 Pandemic affected
globally the health system, health nancing, at the time when the global health systems were
unprepared for it. The COVID-19 crisis has brought social protection to the forefront as a crisis
response tool. Several social protection interventions were implemented and scaled up across
several developing countries, to serve as a COVID-19 response mechanism.
to examine the various social protection interventions and assess their impacts towards
acceleration of resource availability for health services, and other spendings to mitigate the
impact of the COVID-19 Pandemic in selected developing countries and to guide future
pandemics response mechanisms in Africa.
Social Protection Crisis Response and System Strengthening Framework was applied in the
context of developing countries. Additionally, Scoping Literature Review was used on various
social protection responses to COVID-19 among developing countries.
Social protection coverage in some selected developing countries were reported and
documented from the review. For example, Pakistan refugees covered by United Nations
High Commission for Refugees’ Emergency Cash Transfer: 31%, Malawi COVID-19 Urban
Cash Intervention (target coverage for 2021 rollout): Around 28% for both refugee and urban
coverage respectively. While in Nigeria, the COVID-19 Urban Cash Transfer (target coverage for
2021 rollout) and Sierra Leone Emergency Cash Transfer were as low as 5% each on the urban
population scheme.
Social protection can be a force to reckon on, particularly during pandemics. It is a far-reaching
instrument towards poverty eradication, increasing access to basic services including health,
education and minimising out of pocket health expenditure among the vulnerable population.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Social protection serves as a gateway to both universal health coverage and attainment of the
Sustainable Development Goals as well as an effective response against pandemics in Africa.
Social Protection, Health System, Health Financing, Pandemic, Africa
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, independent Consultant, Ouagadougou, Burkina Faso and Hélène Barroy,
WHO, Geneva, Switzerland
Sub-Saharan African countries face a shortfall in funding, especially public funding, to achieve
UHC and the SDGs by 2030. More effective and efcient management of available public
resources would enable countries to reduce waste and achieve better health outcomes.
Improving the effectiveness and efciency of health spending depends on the ability of
governments to ensure strengthened public nancial management (PFM). Advocacy for PFM
requires evidence of its positive effect on health system performance.
This paper examines the effect of PFM quality on health outcomes using ordinary least squares
(OLS), based on a sample of countries in sub-Saharan Africa. The results indicate that better
PFM quality, proxied by PEFA scores, reduces maternal and child mortality. The estimated
effect on non-communicable disease (NCD) mortality is not statistically signicant.
Further analysis by PFM dimension reveals overall negative and signicant effects on maternal
and child mortality and a non-signicant effect on NCD mortality. Results-based budgeting
remains associated with insignicant effects on mortality indicators, while external audits have
no statistically signicant effect on maternal mortality. Predictability and control in budget
execution is the PFM dimension associated with the highest effect on maternal and child
mortality.
The evidence shows that the quality of PFM reduces maternal and child mortality in countries
that prioritize the health sector most in their budget allocation. These effects remain
insignicant in those where health is less prioritised. Effective governance and political stability
and the absence of socio-political violence increase the negative effect of PFM quality on
maternal and child mortality.
1, Amadou Bamba1 and Mamady SISSOKO2, (1) University of Social Sciences
and Management of Bamako (USSGB), Bamako, Mali, (2)University of Social Sciences and
Management of Bamako (USSGB), Bamako, Mali
The coronavirus pandemic has had negative effects on economic, social and political activities
worldwide. The implementation of the barrier measures declared by the WHO in March 2020
has affected many vulnerable people, including pregnant women. These restrictive measures
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
are likely to inuence pregnant women’s attendance at health facilities but may also affect
their psychological health. The low rate of spread of Covid in Mali means that the population
has a different perception of the disease and does not appreciate the barrier measures in
the same way. It is therefore necessary to examine the perception of pregnant women about
Covid-19 and the barrier measures in order to prevent and limit the contamination of this at-
risk segment of the population.
The objective of this article is to nd out the determinants of pregnant women’s perception
of CORONAVIRUS disease and to analyse the effect of the perception of Covid on prenatal
consultations.
A non-probability sample with the quota technique was used to interview 200 pregnant
women in the (6) reference health centres of the Bamako district at the end of September
2021. On the one hand, the partial results of the Multiple Correspondence Analysis (MCA) show
that women who declare that covid-19 is an invented disease are married with a higher level
of education and do not regularly listen to information on covid-19. Those who think that covid
is a God-made spring are single women with secondary education. Those who think covid-19
is a mystical disease are of divorced marital status and have no education. Of the women
surveyed, 92% do not regularly listen to information on Covid, 95% are not vaccinated, 98%
declare not to trust vaccines and government communications on Covid, and nally, Covid
measures have affected prenatal consultations for more than 80% of them. On the other hand,
the econometric analysis conrms that the level of perception negatively inuences prenatal
consultations during the pregnancy period. Awareness-raising policies do not seem to have
had the desired effect, leaving many doubts about Covid-19, even among those at risk, i.e.
pregnant women.
Covid-19, antenatal consultation, maternal health, Mali.
1, Marie Laure Tiade¹, Régine Attia¹, Aissata Dagnogo¹, Kouame Kof¹, Annita
Hounsa², Madikiny Coulibaly³, Simone Malik³, Desquith Ak, Stéphane Serge Agbaya Oga¹,
Luc Philippe Kouadio¹ and Julie-Ghislaine Sackou¹, (1)UNIVERSITE F H BOIGNY, ABIDJAN,
Côte d’Ivoire (2)UFR of pharmaceutical and biological sciences of the Félix Houphouët Boigny
University, Côte d’Ivoire, (3) NATIONAL INSTITUTE OF PUBLIC HEALTH, ABIDJAN, Côte d’Ivoire
The purpose of not seeking care is to identify unmet needs for care that a health condition
would have justied. This behaviour seems to be more frequent among women than among
men. The objective of this study was to analyse the determinants of the renunciation of care
among women in the city of Abidjan.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
This was a cross-sectional study conducted from March to May 2019 in Anonkoi-3, a peri-urban
neighbourhood in the commune of Abobo, north of the city of Abidjan. Socio-demographic,
economic, health status and health care abandonment characteristics of women in the
neighbourhood were collected by means of a questionnaire. Univariate analyses and logistic
regression models were used to measure the association between the different types of
renunciation and each of the women’s characteristics.
The sample consisted of 423 women with a mean age of 32 ± 12 years. Renunciation of
consultations with general practitioners concerned 72.3% of the women. Among the
specialists, consultations with the ophthalmologist (25.1%), the dentist (22.0%), and the
gynaecologist (14.9%) were the ones that women gave up the most. After the consultation,
31.2% of them gave up on other care. They most often refused to buy conventional medicine
(19.6%) and preferred to use street and traditional medicines (87.9%).
All other things being equal, women aged 28 to 38 (OR= 2.5 [1.3-4.7], p= 0.013), craftswomen and
shopkeepers (OR= 3.2 [1.5-7.4], p= 0.004) and those learning a trade (OR= 2.4 [1.1-5.5], p=0.028)
gave up signicantly more care.
Socio-economic inequalities seem to be most important for women, which leads them to
forego care. It is therefore necessary to work to reduce these inequalities.
Women, renunciation of care, precariousness, social inequalities, Ivory Coast
, Université Cheikh Anta Diop, Thiès, Senegal, Abdoulaye Diallo, Ministry of
Health of Senegal, Senegal and Samba Cor Sarr, Ministry of Health of Senegal, Dakar,
Senegal.
Access to reproductive health services is a right for all. Senegal is therefore committed to
programmes aimed at improving the health of individuals, particularly adolescents.
To establish promising interventions for improving adolescent reproductive health in Senegal.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
To form a working group bringing together researchers, decision-makers, and structures
in charge of adolescent health in Senegal to develop different interventions in adolescent
reproductive health in Senegal.
Based on WAHO criteria and taking into account the country’s ARH needs, we selected a set
of criteria. The scoring method applied to these criteria made it possible to select the different
priority interventions in adolescent ARH in Senegal.
Several areas of ARH interventions in Senegal were selected. The criteria included
consideration of social determinants, consideration of proximal determinants, consideration
of knowledge, behaviours and lifestyle of adolescents, sustainability, innovation, potential for
scaling up, consideration of cultural values and maturation. Four interventions were selected
as promising interventions. These were the girls’ schooling project, the promotion of family life
education clubs, the school pregnancy eradication project and the teen/youth spaces.
Through a systematic approach, this study identied promising interventions to ensure
improved adolescent reproductive health in Senegal. Therefore, this research is essential to
support effective initiatives to improve adolescent reproductive health in Senegal.
, Institute of Statistical, Social and Economic Research, Accra,
Ghana
Globally, Africa is considered to be a very young and growing continent, with more than half
of the population under the age of 30. In the Economic Community of West African States
(ECOWAS) region in particular, more than 33% of the population is aged between 10 and
24. Therefore, the potential demand for Adolescent Sexual and Reproductive Health (ASRH)
services among the young population is expected to be high. Although some countries
have developed plans to address and improve ASRH, there is a lack of information on the
cost of these interventions. There is also little or no information on the lack of resources or
the requirements for scaling up these interventions. The study aims rst to identify ‘priority’
or effective interventions to improve ASRH in Ghana and Senegal. Second, these identied
interventions will be costed. The study will also assess resource needs, funding gaps and
identify funding strategies to implement priority ASRH interventions in Ghana and Senegal
using a multi-component and multi-sectoral approach. Finally, in collaboration with key
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
national stakeholders, the study will develop innovative and sustainable resource mobilization
strategies for nancing priority or effective ASRH interventions in Ghana and Senegal. Given
that government health budgets in Africa remain low, it is important to understand effective
ways to mobilise equitable and sustainable domestic resources to fund ASRH interventions in
Africa. The criteria for identifying priority ASRH interventions are based on the West African
Health Organization (WAHO) framework for identifying effective interventions to address
ASRH challenges. Our preliminary results suggest that priority ASRH interventions in Ghana
are largely those classied as cross-cutting and multi-sectoral, including adolescent clubs,
adolescent empowerment interventions, capacity building interventions and digital health
interventions.
, Cheikh Anta Diop University, Thiès, Senegal
Access to reproductive health services is a right for all. Senegal is therefore committed to
programmes aimed at improving the health of individuals, particularly adolescents.
To establish promising interventions for improving adolescent reproductive health in Senegal.
To form a working group bringing together researchers, decision-makers, and structures
in charge of adolescent health in Senegal to develop different interventions in adolescent
reproductive health in Senegal.
Based on WAHO criteria and taking into account the country’s ARH needs, we selected a set
of criteria. The scoring method applied to these criteria made it possible to select the different
priority interventions in adolescent ARH in Senegal.
Several areas of ARH interventions in Senegal were selected. The criteria included
consideration of social determinants, consideration of proximal determinants, consideration
of knowledge, behaviours and lifestyle of adolescents, sustainability, innovation, potential for
scaling up, consideration of cultural values and maturation. Four interventions were selected
as promising interventions. These were the girls’ schooling project, the promotion of family life
education clubs, the school pregnancy eradication project and the teen/youth spaces.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Through a systematic approach, this study identied promising interventions to ensure
improved adolescent reproductive health in Senegal. Therefore, this research is essential to
support effective initiatives to improve adolescent reproductive health in Senegal.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
James Avoka Asamani, World Health Organization, Harare, Zimbabwe and Juliet Nabyonga-
Orem, World Health Organization, Brazzaville, Congo, Brendan Kwesiga, WHO Kenya Country
Ofce, Nairobi, Kenya, hristmal Dela Christmals, North-West University, Potchefstroom, South
Africa.
As countries in the African region seek to transition to higher-income status, it is expected
that there would be a corresponding reduction in external donor funding, and governments
would have to rely on domestic sources to fund health services increasingly. In addition, shocks
to economies such as the impact of the COVID-19 pandemic have hurt African countries with
already sub-optimal levels of health system performance. Therefore, improving efciency
in health systems across African countries is urgent now than ever. Previous studies have
examined the technical efciency of healthcare delivery institutions and others on system-
wide analysis of (in)efciency within countries or across countries. Nevertheless, depending
on the input and output measure selected and the methodological choices and rigour, the
available evidence on health system efciency in Africa seem to be inconsistent, sometimes
conicting or even confusing. We conducted a series of analyses to systematically assess
the level of (in)efciency of health systems in Africa and the associated explanatory factors,
triangulating from the literature and empirical analysis. This organized session presents three
(3) papers that address the efciency in Africa from a systematic literature review and meta-
analysis, a multicounty data envelopment analysis and a country case study from the lens of
cross programmatic efciency in the context of donor transition.
Christmal Dela Christmals, North-West University, Potchefstroom, South Africa, Juliet
Nabyonga-Orem, World Health Organization, Brazzaville, Congo and James Avoka Asamani,
World Health Organization, Harare, Zimbabwe
Low-and-middle-income countries, especially in Africa, have inadequate domestic resources
to invest in health towards attaining universal health coverage (UHC), but the available
resources have not always been used efciently. Thus, in addition to the advocacy for increased
investments in health, countries must improve efciency and provide more healthcare services
within the limitation of their resources. It is, thus, necessary to understand the level of (in)
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efciency in Africa and what drives it. This systematic review synthesized up-to-date evidence
on the level of (in)efciency of health systems in the Africa region and its drivers.
A systematic literature review was conducted, guided by the PRISMA 2020 statement.
Related studies were grouped and meta-analyzed, while others were descriptively analyzed. A
qualitative content synthesis was employed for synthesizing the drivers of efciency.
Overall, 39 studies met a predetermined inclusion criterion and were included from a possible
4,609 records retrieved through a rigorous search and selection process. Using the random-
effects restricted maximum likelihood (REML) method, the pooled efciency score for the
Africa region was estimated to be 0.77 (95% CI: 0.66-0.83) – implying that on the ip side, health
system inefciencies across countries in the African region was approximately 23% (95%: 17%
- 44%). Across 22 studies that used Data Envelopment Analysis (DEA) to examine efciency at
health facilities and sub-national entities, the efciency level was 0.67 (median efciency score
= 0.65). Thus, facility-level studies tended to estimate low levels of efciency as compared to
health system-level studies. Across the studies, 21 signicant drivers of efciency, including
population density of the catchment area, governance, health facility ownership, health facility
staff density, national economic status, type of health facility, education index, hospital size and
duration of inpatient stay (bed occupancy rate) were reported.
With approximately 23% (17-34%) inefciency in the health systems in Africa, improving
efciency alone will yield an average of 34% improvement in resource availability in Africa
-assuming all countries are performing similar to the frontier countries. However, with the
low level of health expenditure per capita in Africa, the efciency gains alone will likely be
insufcient to meet the minimum requirement for universal Health Coverage.
James Avoka Asamani, World Health Organization, Harare, Zimbabwe and Juliet Nabyonga-
Orem, World Health Organization, Brazzaville, Congo
The 2010 World health report highlighted improvements in health system efciency as a
critical factor in achieving universal health coverage (UHC) as 20-40% of all resources spent on
healthcare are estimated to be wasted (WHO, 2010). Therefore, there is a need for increments
in healthcare expenditure on the one hand and the need to improve efciency, on the other
hand, to manage health care costs better and improve health outcomes and sustainability
towards UHC. Using a systematic review of evidence to guide variable selection, this presents
ndings of a cross-sectional data envelopment analysis (DEA) to estimate the level of (in)
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efciency in countries and the underlying factors driving inefciency.
We examined technical efciency using the Data envelopment analysis (DEA). The inputs
used in the DEA are Current Health Expenditure per capita (CHE), health workers and hospital
beds per 1000 populations. The output measurements of health system outcomes were life
expectancy at birth and under-5 mortality.
Analysis is ongoing, and the preliminary estimates show that the Africa region has an average
efciency score of 75.41% (95% CI: 69.05% - 81.76%), the lowest, however, 34.8% in Cameroon
while ten countries are likely efciency frontiers. Also, 21 countries (44.68%) seem technically
efcient, but 23 (49%) have signicantly lower efciency scores than the frontier countries
and could be considered technically inefcient. Some countries ranked lowly in the output-
oriented model had a relatively better rank when considered for the input-oriented model. In
the second stage analysis, a Tobit regression model is used to explore the main divers of the
differences in efciency scores between countries. The preliminary results of this empirical
analysis tend to be consistent with meta-analysis from a systematic review, but substantial
variations are observed in some countries, which points to the uncertainties surrounding
multi-country health system-level efciency analyses. Hence, cross-sectional efciency analysis
should always be interpreted with caution – thus, regular analysis to track changes over time
may be more informative for system improvements.
Inefciency is prevalent in 49% of the Africa region. This must, however, be interpreted with
caution as efciency scores are highly sensitive to the selection of variables, period of data and
choice of methodology.
Brendan Kwesiga, WHO Kenya Country Ofce, Nairobi, Kenya
Meaningful progress towards Universal Health Coverage (UHC) will depend on resources
being available to the health sector to provide sufcient coverage with quality health
services. However, Kenya’s renewed focus on moving towards UHC comes when donors are
transitioning from directly supporting the health sector. Kenya’s commitment to UHC provides
an opportunity for Kenya to approach donor transition from a UHC lens to ensure sustainability
and system resilience. With this background, this study set out to identify cross programmatic
inefciencies in implementing priority health programs that depend signicantly on donors
and explore ways of addressing them.
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Using a cross-sectional design, data were collected through document review and key
informant interviews and at national and in a sample of three counties. We adopted a system-
wide approach to analyzing efciency across the selected health programs. The selected
programs were HIV, TB, Immunization, RMNCAH, & Malaria. The approach included mapping
implementation of the programs across the four core health system functions (service delivery,
stewardship/ governance, generation of human and physical resources/inputs and health
nancing). Based on this, we map areas of duplication, overlap and misalignment between the
different programs across the broader health system aspects related to the programs.
Donor funded programs in Kenya have multiple funding ows and different incentive
structures that result in misalignment with broader health system goals. On the input side,
there is still program based human resource management leading to duplicative roles,
suboptimal staff performance and overreliance on contracted staff. Despite previous efforts on
supply chain rationalization, there is still fragmentation in supply chains resulting in a lack of
coordination in supplies and complimentary compromising access to health services. There are
also challenges observed in multiple data systems and mechanisms for reporting, data quality
assurance and data use across the programs. The misalignments across the health system
functions and the governance structures for the programs affect effective service delivery,
including public health functions.
As countries plan to transition from donor resources while on the path to scaling up UHC, the
focus should not just be on aiming at just replacing donor dollars with domestic dollars as this
is neither efcient nor sustainable. Cross programmatic efciency identies potential health
system overlaps/misalignments that could be addressed as Kenya transitions from donor
support to sustain access to priority services and the system becomes more resilient.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Yewande Ogundeji, Health Strategy and Delivery Foundation, FCT, Canada, Wenhui
Mao, The Center for Policy Impact in Global Health, Durham, NC, Osondu Ogbuoji, The Center
for Policy Impact in Global Health, Durham, NC.
The global health landscape is undergoing a rapid and profound set of transitions that
threaten to stall or even derail progress in health improvement. Over the next few years,
more than a dozen lower middle-income countries (LMICs) will graduate from multilateral
development assistance in health (DAH), yet many still have large pockets of poverty and high
mortality and lack the domestic capacity to tackle these challenges alone.
Gavi and the Global Fund to Fight AIDS, TB, and Malaria, US President’s Emergency Program
for AIDS Relief (PEPFAR), are major players in the nancing of disease control programs. Since
2000, over US$ 109 billion and US$ 24 billion have been spent by donors on HIV programs and
vaccination respectively. As countries are experiencing economic growth, a shift is expected
from external donor funding for health towards domestically funded systems that deliver
results. Accordingly, in recent years, donors have begun tapering (or have plans in place to
taper) foreign development assistance. However, there is evidence that large-scale public
health programs are often not sustained beyond donor support.
Consequently, it is important to analyze risks, gaps, and challenges, as well as resource
implications as countries prepare for these transitions. Insights from these assessments
will facilitate better planning to ensure that programmatic gains are sustained upon donor
withdrawal.
The proposed organized session will present country perspectives on transition preparedness,
Including resource and policy implications, and experience with transition planning in Ghana
and Nigeria. The rst presentation will focus on ndings from interviews and discrete choice
experiments with stakeholders in Ghana to explore their perspectives on transition. The second
presentation will present evidence from benet incidence analysis highlighting Who benets
from the Expanded Programme on Immunization (EPI) in Ghana. The third presentation
will highlight knowledge, capacity, and policy gaps (and opportunities) relevant to funding
transitions in Nigeria. The nal presentation will focus on stakeholders’ experiences with
planning for Nigeria’s transition from Gavi nancing for routine immunization.
Wenhui Mao, The Center for Policy Impact in Global Health, Durham, NC
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Ghana’s shift from low-income to middle-income status will make it ineligible to receive
concessional aid in the future. While transition may be a reection of positive changes in a
country, such as economic development or health progress, a loss of support from donor
agencies could have negative impacts on health system performance and population health.
We aimed to identify key challenges and opportunities that Ghana will face in dealing with aid
transition and analyze the preferences of in-country stakeholders for potential policy options to
manage donor exits.
We conducted key informant interviews and a binary choice Discrete Choice Experiment (DCE)
with attributes and levels developed based on interviews. We performed directed content
analysis of the interview transcripts and data from DCE was analyzed by tting a Hierarchical
Bayes model using Lighthouse Studio 9.7 (Sawtooth Software).
18 stakeholders from the government, civil society organizations, and donor agencies in Ghana
identied challenges more frequently than opportunities. All stakeholders believe that Ghana
will face substantial challenges due to donor transitions. Challenges include: difculty lling
nancial gaps left by donors, the shifting of national priorities away from the health sector,
lack of human resources for health, interrupted care for beneciaries of donor-funded health
programs, neglect of vulnerable populations, and loss of the accountability mechanisms
that linked with donor nancing. However, stakeholders also identied key opportunities
that transitions might present, including efciency gains, increased self-determination and
self-sufciency, enhanced capacity to leverage domestic resources, and improved revenue
mobilization.
We analyzed data from 76 respondents; 50 (68.5%) were from government agencies, nine
(12.3%) from non-governmental organizations (NGOs), and seven (9.6%) from donor agencies.
Stakeholders agreed that a transition readiness assessment was needed and developing a
national transition management plan was strongly preferred. Stakeholders preferred that
the government alone should bear the primary responsibility for transition preparedness. For
post-transition funding for health, stakeholders preferred increasing government allocation to
health over the other options. For systems strengthening interventions, stakeholders preferred
improving efciency of the health sector.
Stakeholders in Ghana believe transitioning away from aid for health presents both challenges
and opportunities. The challenges could be addressed by conducting a transition readiness
assessment, identifying health sector priorities, developing a transition plan with a budget
to continue critical health programs, and mobilizing greater political commitment to health.
The loss of aid could be turned into an opportunity to integrate vertical programs into a more
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
comprehensive health system.
Osondu Ogbuoji, The Center for Policy Impact in Global Health, Durham, NC
Ghana’s expanded programme on Immunization (EPI) is mainly funded by government,
with signicant support from donors including Gavi, the Vaccine Alliance. As Ghana has
become a lower middle-income county and is approaching graduation from Gavi, we aim to
assess who will be most affected by the Gavi transition by analyzing who benets the most
from the current EPI. Using service use data from the 2017 Living Standards Survey and cost
information from secondary sources, we conducted a benet-incidence analysis to assess
if households from lower socioeconomic groups preferentially beneted from the EPI in
Ghana. We specically included polio, Penta, Rotavirus, Measles, Vitamin A, BCG, and Yellow
fever vaccinations for analysis. We found that over 96% of children under ve years have been
vaccinated in Ghana, with higher coverage in the urban areas (99.3%) than in rural areas (94.9%)
and equal (96.4%) for both male and female children. Coverage was lower (93.9%) among
poorer households compared to the wealthier (99.1%) households. A small fraction (7.4%) of
households made direct out-of-pocket payments for the immunization services received. The
proportion was higher in rural areas (8.3%) compared to urban areas (5.5%). The distribution of
benet from the selected EPI vaccines were pro-poor for the whole population regardless of
types of vaccines and the CI ranges from -0.087 to -0.153 (p<0.05). In other words, the poorer
households preferably beneted more from the current EPI program in Ghana, and they tend
to be affected more after Ghana graduates from donor’s support on EPI programs. To address
this concern and to maintain the equitable distribution of vaccine services after transition,
more resources need to be mobilized domestically to support the EPI program. It is therefore
important for Ghana to adopt a strategy going in to a complete transition that will prioritize
resource mobilization and allocation for program such as the NIP that received signicant
donor support.
Yewande Ogundeji, Health Strategy and Delivery Foundation, FCT, Canada
Nigeria is undergoing transitions in the healthcare system that include a double burden of
infectious and non-communicable diseases, and transition from concessional donor assistance
towards domestic nancing for health. These transitions will affect Nigeria’s attainment
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of universal health coverage (UHC). Therefore, it is important to analyze current policies,
stakeholders’ capacity, and knowledge for UHC advancement within the context of these
transitions.
We conducted a qualitative study, including document review and semi-structured interviews
with 18 key informants (KIs) from government ministries, departments, and agencies (MDAs),
development partners, civil society organizations, and academia. The interview transcripts
were analyzed using NVivo 11 to identify themes based on similarities and differences in the
data.
Stakeholders were generally knowledgeable about the transitions that Nigeria faces,
particularly around disease burden, donor assistance, and domestic nancing, but not
demographic transitions. Capacity gaps identied by respondents included poor capacity
to implement health insurance schemes at subnational levels, poor information/data
management to monitor progress towards UHC, and limited communication and interagency
collaboration between MDAs. Furthermore, participants in our study expressed that current
policies driving major health reforms like the National Health Act appear adequate to
support UHC advancement in theory, but poor policy implementation is a key challenge. Key
informants emphasized that this poor implementation was due to a lack of policy awareness,
low government spending on health, and poor evidence generation for information to support
decisions.
The study found that there are major challenges in terms of knowledge and capacity for UHC
advancement in the context of these transitions, including poor knowledge of demographic
transitions, poor capacity for health insurance implementation at sub-national levels, low
government spending on health, poor policy implementation, and poor communication
and collaboration among stakeholders. To address these challenges, collaborative efforts
are needed to bridge knowledge gaps through targeted knowledge products, improved
communication and inter-agency collaboration, and increased policy awareness by identifying,
engaging, and building the capacity of policy champions for domestic resource mobilization
and other health nancing reforms.
Yewande Ogundeji, Health Strategy and Delivery Foundation, FCT, Canada
Childhood immunization is one of the most cost-effective public health interventions to reduce
child mortality. However, Nigeria still has the highest number of unimmunized children in
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the world, estimated at 4.3 million children in 2018. Since 2000, Gavi, the Vaccine Alliance, has
worked to improve access to new and underused vaccines for children living in the world’s
poorest countries as part of attaining universal health coverage. In June 2018, the Board of Gavi
approved an extension of the transition period of its immunization support to Nigeria from
2021 to 2028. Nigeria is now expected to transition to the fully self-nancing phase, assuming
full responsibility by 2028. This self-nancing will require scaling up of budgetary provisions by
the government of Nigeria for immunization over the period 2019-2028. To improve Nigeria’s
efforts towards self-nancing of routine immunization, we provided technical assistance on the
development of a monitoring framework for monitoring and tracking immunization nancing;
we also engaged key stakeholders to validate and align on the framework.
First, we conducted a desk review of the immunization nancing space to understand
the players and activities in the landscape. Then we performed diagnostics and analysis to
develop a vaccine nancing monitoring framework. Additionally, we conducted key informant
interviews with 12 stakeholders involved in RI programming at the National level. Transcripts,
notes, and memos from the interviews were coded and analyzed thematically.
Overall, the ndings from the study indicate that the federal government of Nigeria (FGoN) is
committed to increasing the budgetary allocation to immunization nancing. The 2021 budget
saw an increase in vaccine nancing as a service-wide vote. Additionally, the application of
the vaccine nancing monitoring framework revealed that the proportion of annual vaccine
procurement expenditure released from government budgetary resources has increased
signicantly in the last two years from less than 5% in 2018 to 28% in 2019 and 33% in 2020.
However, some stakeholders expressed the need to move immunization nancing to a rst-
line charge in the budget, so it remains guaranteed in the budget for immunization nancing.
The ndings from the key informant interviews highlighted the different roles of stakeholders
in the current country coordinating mechanism for routine immunization. Stakeholders
conrmed that there are several processes in place to avoid the misuse of funds, which involve
tracking specic indicators and navigating existing bureaucracies with the disbursement of
funds.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University of Bamenda, Cameroon, Bamenda, Cameroon
Globally, health concerns have been on a rise ranging from malnutrition, non-communicable
diseases, climate change, and above all infectious disease burden. The recent COVID- 19
outbreak has uncovered weaknesses within global healthcare systems. COVID-19 has ignited
debates amongst health experts, economists, and politicians worldwide. This has also led to
polarization in international politics affecting health globally. The resulting division has taken
focus away from the global response needed to curb the deadly disease, resulting in slow
economic advancements and millions of lives lost and yet the solution still seems futile.
We sought key stake holders’ perceptions and views on the impact of politics in global health
challenges with particular interest on the COVID-19 pandemic in the northwest region of
Cameroon. And how these perceptions guide their healthcare seeking behaviors.
A purposive sampling method was used to identify 300 key stake-holders and a face to face
questionnaire administered. The data was analyzed using a thematic analysis to identify their
perceptions of the political impact on COVID-19 pandemic and to decipher their healthcare
seeking behaviors.
The conventional medicine had her integrity questioned and their role belittled by 74% and
58% respectively in the context of COVID-19. Sixty-eight percent of the stake holders resorted to
what they believed works best for them. And 87 % blamed political/administrative pressure as
the root-cause of COVID-19 vaccine denial, and refusal to use conventional healthcare services
for COVID-19 treatment.
There should be global response to a pandemic like COVID-19. Science has been trusted
for years and should be given the right of place in the context of health crisis. Scientic
research and nding should have huge support from the political/governing powers. Political/
administrative pressure in the context of health crisis like the COVID-19 can be hugely
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counterproductive.
1, Lucy Gilson2, Benjamin Tsofa3, Edwine Barasa4 and Marsha Orgill2, (1)
Kemri-Wellcome Trust Research Programme, Nairobi, Kenya, (2)University of Cape Town,
South Africa, (3)KEMRI-Wellcome Trust Research Programme, Kili, Kenya, (4)Health
Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
Performance based nancing was introduced to Kili county in Kenya in 2015. This study
investigates how and why political and bureaucratic actors at the local level in Kili county
inuenced the extent to which PBF was politically prioritised at the sub-national level.
The study employed a single-case study design. The Shiffman and Smith political priority
setting framework with adaptations proposed by Walt and Gilson was applied. Data was
collected through document review (n=19) and in-depth interviews (n=8). Framework analysis
was used to analyse data and generate ndings.
PBF was not prioritised at the county level in Kili after donor funding for the initiative ended
in 2018. Political prioritisation of PBF at the county level in Kili was inuenced by contextual
features including the devolution of power to sub-national actors and rigid public nancial
management structures. It was further inuenced by interpretations of the idea of ‘pay-for-
performance’, and specically, its framing as ‘additional funding’, as well as over key PBF
design features.
Health reformers must be cognisant of the power and interests of national and sub national
actors in all phases of the policy process, including both bureaucratic and political actors in
health and non-health sectors. This is particularly important in devolved public governance
contexts where reforms require sustained attention and budgetary commitment at the sub
national level. There is also need for early involvement of critical actors to develop shared
understandings of the ideas on which interventions are premised, as well as problems and
solutions.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, University of Nigeria, Nsukka, Nsukka, United Kingdom, Adanma Ekenna,
Health Policy Research Group, University of Nigeria, Enugu Campus, Enugu State, Nigeria,
Uche Obi, Health Policy Research Group, Enugu State, Nigeria, Tochukwu Orjiakor, University
of Nigeria, Nsukka, Aloysius Odii, University of Nigeria, Nsukka, Nsukka, Enugu, Nigeria, Enyi
Etiaba, University of Nigeria, Nsukka., Enugu, Nigeria, Benjamin Chudi Uzochukwu, University
of Nigeria Enugu Campus, Enugu, Nigeria and Obinna Onwujekwe, University of Nigeria,
Nsukka, Enugu Campus, Enugu, Nigeria
Flexible and urgent health spending during public health emergencies distorts procurement
processes and potentially encourages corrupt practices in health systems. This can erode
public condence, resulting to poor compliance to health safety measures during public
health crisis. Thus, anticorruption in health, and in pandemic responses is key.
Our review aims at underscoring the COVID-19 resource space in Nigeria, reecting through
generated resources and how they were used. We sought to understand corruption areas
that might have affected optimal use of aggregated resources to optimize responses to the
pandemic. Also, we try to look out for evidence of anticorruption within the Nigerian space, and
around similar low resource settings which we can build upon in future.
COVID-19 related articles (reports from various government bodies and CSOs) on resource
mobilization, appropriation, public perceptions towards accountability and anticorruption,
were reviewed. were organised under three themes: i) mobilized resources for
COVID-19, ii) evidence of corruption or anticorruption in spending them and iii) implications for
health systems governance.
About N36.3b ($US93.5m) was raised through 295 donations to federal and state governments,
to combat the virus. Additionally, Nigeria appropriated N10b ($27m) to epi-centres and the
disease control agency in the country. Whilst information on available resources are freely
available, that on expenditure has been opaque, which has generated heated concerns. While
anticorruption evidence appears scarce in our review, we were able to identify a few. Key to the
anticorruption measures we found is the involvement of the grassroots.
Lack of evidence of optimal utilization of resources under the frames of accountability and
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
anticorruption has aroused public concerns and trust in the actual existence of a pandemic.
Diminished health worker motivation connects with industrial actions.
CSOs need to be actively engaged in driving government to show accountability, through
partnering with multilateral organisations and donors to increase pressure on government to
be accountable with resources mapped out for pandemic responses. Health workforce groups
and Associations also need to actively engage government and demand accountability. Finally,
conversations on corruption and accountability issues that affect health systems should be
encouraged.
, American University in Cairo, Cairo, Egypt and Aliaa Aboutera, American
University in Cairo
The international aid (IA) industry suffers from coordination difculties on vertical and
horizontal levels due to the presence of various actors in such industry. The main objectives
of the study are to explore the IA actors, means of IA coordination and relate these means to
concepts of coordination. The study analysis the IA coordination structure using the Bouckaert
et. al (2010) conceptualization of the theoretical models of coordination.
According to the analysis, the three models of coordination are present in the case of IA.
Hierarchy-based model is present in the vertical coordination between the central level and
periphery level in the public sector as well as between donors / international organizations and
recipient governments. Hierarchy guarantees rules based relations but poses the challenge
of rigidity resulting in decreased alignment of aid. Network-based model can be detected in
horizontal coordination between ministries involved in multi-sectoral aid funded programs
and between donors. Network-based coordination helps in reducing duplicity and waste
of resources. Nevertheless, it is based on trust and information sharing which is not always
present between different actors. Market-based coordination takes place between government
on one side and NGOs or private for prot organizations on the other side. It is seemingly
an easy coordination approach, nonetheless, it depends on NGOs and private organizations
capacities.
Different coordination structures were established at both international and national levels to
overcome the complexity of coordination between the numerous IA actors. These structures
proved to suffer many shortcomings. IA coordination structures’ shortcomings are due to:
rst, the large numbers of actors with different jurisdictions which requires a comprehensive
complex method of coordination. Second, all aid coordination structures, except for some
structures created by governments, concentrate on one type of actors, they do not cover the
long chain of actors in aid. Thus they facilitate coordination at one step of the aid process but
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
not along the entire process. And third, network coordination approach is greatly used in aid
although it is the most fragile type of coordination.
The paper recommends the strengthening of recipient government coordination structures to
be able to coordinate aid within its institutions and with donors, IOs, NGOs and private sector
as a promising solution to the international coordination problem. The paper also concludes
that further research is required to develop more effective coordination mechanisms that
encompass all actors in the IA chain.
, University of Ghana Business School, Accra, Ghana, Augustina Koduah,
2Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, College of
Health Sciences, University of Ghana, Accra, Ghana and Gilbert Abiiro, Department of Health
Services, Policy, Planning, Management and Economics, School of Public Health, University for
Development Studies, Tamale, Ghana
Ghana became the rst African country to take delivery of the rst wave of AstraZeneca/
Oxford vaccine from the COVAX facility. This promising start of the vaccination roll out is
yet to translate into accelerated full vaccination of many populations. The arrival of the
COVID-19 vaccines and the vaccination process have been subjects of intense internal political
contentions characterised by diverse interpretations and issue characteristics of the vaccines
that adversely shape attitudes to vaccination. Drawing on the tenets of a policy analytical
framework, we conducted a rapid review of media reports, journal articles and documents
reports on ongoing debates, discussions and issues relating to political dynamics, framing
of the vaccination, social constructions generated around the vaccines and stakeholders’
actions linked to the development trajectory of the vaccination. We found that the COVID-19
vaccination has mainly been framed along the lines of public health, gender-centredness
and universal health coverage. Vaccine acquisition and procurement were riddled in politics
between the ruling government and the largest main opposition party. While the latter
persistently blamed the former for being politically rhetoric rather than tactically responsive
in supplying sufcient vaccines, the former blamed the inability to secure vaccines on vaccine
nationalism crowding out fair distribution. Government’s efforts to increase vaccination
coverage to target levels were stied when a deal with private suppliers to procure 3.4
million doses of Sputnik-V turned dramatic and collapsed. Amidst the vaccine scarcity, the
government developed a working proposal to produce vaccines locally which attracted
considerable interests among pharmaceutical manufacturers, political constituents and donor
partners. Regarding issue characteristics, hesitancy for vaccination linked to ill perceptions of
vaccines safety provoked political led vaccination campaigns to induce vaccine acceptance.
In conclusion, scaling up vaccination requires political unity, harmonised frames, managing
stakeholder interest and tackling risk factors undermining vaccination as a social duty.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Muhammed Muhammed, Hyeladzira Garnvwa and Sarah Martin,
National Primary Health Care Development Agency (NPHCDA), Abuja, Nigeria
Health Financing is key in building resilient health systems and essential for countries to
achieve Universal Health Coverage. As health systems globally work to re-build and restructure
following the COVID-19 pandemic, it is crucial that sustainable health nancing is embedded
into these plans.
To review the role of health nancing in health systems strengthening, and its role in
supporting the development of resilient Primary Health Care (PHC) systems which can better
respond to future pandemics. Furthermore, examine how health nancing can be used
alongside other health systems pillars such as Human Resources for Health (HRH) to improve
coverage of essential health services and ultimately achieve Universal Health Coverage (UHC).
A desk review was carried out to analyse the current composition of health nancing at
the PHC level within Nigeria, and how this interacts with health systems performance and
the achievement of national and international targets. Evidence of the country’s progress
towards achieving UHC was also reviewed, through analysis of quantitative data on varying
components of UHC, such as service coverage, equity, and nancial protection. A review of the
current policy in place to support progress towards UHC was also undertaken, with emphasis
on how it can be further strengthened given the changing macroeconomy in the post-covid
era. Finally, a scoping review was carried out to understand further the interaction between
health nancing and other health pillars such as HRH in achieving national health targets such
as increasing coverage of essential health services.
The study identied the critical role that health nancing has in accelerating progress towards
UHC in Nigeria, with a focus on ensuring sustainability and innovation in the application of
health nancing methods. Options for accelerating progress towards crucial components
of UHC were outlined, exploring the joint role of HRH and other health pillars in achieving
resilient health systems.
Sustainable health nancing is key to building resilient health systems following the COVID-19
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pandemic, and essential in achieving the goal of Universal Health Coverage. It must be used
alongside HRH other health pillars to be most effective. As the health systems globally aim to
re-build following the COVID-19 pandemic, health nancing must be at the centre of these
plans.
, Dodowa Health Research Center, Dodowa, Ghana, Nana Efua Enyimayew
Afun, Dodowa Health Research Centre, Dodowa, Ghana, Genevieve Cecelia Aryeetey,
University of Ghana School of Public Health, Accra, Ghana, Justice Nonvignon, Department
of Health Policy, Planning and Management, School of Public Health, University of Ghana,
Legon, Ghana, Irene Akua Agyepong, Ghana College of Physicians and Surgeons, Accra,
Ghana and Anthony Ofosu, Ghana Health Service, Accra, Ghana
Public health emergencies are complex and the involvement of and coordination between
multiple sectors is important for health emergency preparedness and response. City-level
governments, in particular, play an important role in responding to complex challenges such
as health emergencies since they are responsible for acting on the wider determinants of
health which sit outside the traditional remit of the healthcare system.
We describe and analyze the actors, governance structures, roles and coordinating
mechanisms and faciliators and barriers within local government and between central and
local government in the Covid 19 response in Ghana during the rst wave of the covid-19
outbreak and lessons for dealing with health security threats in low and middle income
countries.
We conducted a single cross sectional case study of two municipalities in the Greater Accra
region of Ghana. Sources of data came from a desk review (with 573 documents – 526 media
reports and 47 reports and strategies) and 23 key informant indepth interviews conducted in
February and March 2021 with local government ofcials and municipal health management
team staff in the two municipalities.
Coordination between the national government and local government was in the form of
directives and guidelines; training, and provision of funds and logistics. Most emergency
response structures at municipal level were functional except some Public Health Emergency
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Mangement Committees. Inadequate resources (funds and logistics) challenged all aspects
of the response. During risk communication, assemblies and health directorates worked in an
uncoordinated fashion. A biased selection and distribution process, as well as a lack of bottom-
up approach in planning and implementation was common during the distribution of relief
items and undermined the possibility of targeting and selecting appropriate beneciaries.
Despite the high commitment of the government of Ghana to a whole of government and
a whole of society approach, local governance of the pandemic was challenged in several
ways. We recommend equipping health facilities for case management and surveillance,
effective monitoring of the distribution of relief items, a bottom up approach to the planning
and implementation of relief interventions, and the identication of additional sources/
mechanisms of nancing public health emergencies at all levels.
1, Ileana Vilcu2, Mbuthia Boniface1, Dr. Musuva Anne1 and Nirmala Ravishankar3, (1)
ThinkWell, Nairobi, Kenya, (2)ThinkWell, Geneva, Switzerland, (3)ThinkWell, Mauritius
Revenue sources for primary health care (PHC) facilities in Kenya include national and county
government grants, Danish International Development Agency (DANIDA) funds, and own-
source revenues such as reimbursements from the National Hospital Insurance Fund (NHIF)
for its various schemes, including the free maternity program Linda Mama. However, PHC
facilities do not always have the necessary funds to provide services, especially during a
pandemic.
This mixed methods study explored the sustainability of public PHC facilities nancing in
Makueni county. We analyzed nancial data from all revenue sources between scal year
(FY) 2017/18 and FY 2020/21 and assessed how the availability of funds impacted PHC facilities’
COVID-19 response.
We carried out in-depth interviews with facility managers and the County Health Management
Team in Makueni and analyzed nancial records from 40 out of 60 public PHC facilities in the
county. We purposively selected facilities based on claims and service volumes to capture 99%
of the Linda Mama data; the other 20 PHC facilities account for only 1% of the total number of
Linda Mama claims in the county.
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Linda Mama revenue, the most signicant own-source revenue for PHC facilities, grew more
than 10 times between FY 2017/18 and FY 2020/21. This is a result of county and facilities efforts
to optimize NHIF claims submission.
In contrast, the national level funding amount, transferred annually, remained constant during
the same time period. County government grants, transferred quarterly, and DANIDA grants
increased in the rst three FYs and reduced by 25% and 50% respectively in FY2020/21. From FY
2021/22, the national grant will no longer be available to all public PHC facilities in Kenya.
Due to routinely delays in disbursement of grants to PHC facilities, managers relied on Linda
Mama revenue to sustain operations during the COVID-19 pandemic to purchase emergency
personal protective equipment, medicines, and pay utility bills.
Linda Mama has proved to be an important and reliable revenue source for Makueni’s PHC
facilities, especially in times of crisis. All public PHC facilities in the county can retain and use
their own source revenue so they were able to immediately use Linda Mama funds when
COVID-19 crisis hit compared to other funding sources which were delayed and only available
periodically. This was crucial for PHC facilities to provide essential and COVID-19 services
and highlights the importance of continuing to increase own-source revenues and facility
autonomy.
1, Sarah Martin2 and Hyeladzira Garnvwa1, (1)Partners for Health Equity
(P4HE), Nigeria, (2)Partners For Health Equity (P4HE), Nigeria
An estimated 2 million people are residing in Internally Displaced Persons (IDP) camps across
the Northeast States of Nigeria, resulting from the decade-long insurgency by the militant
group Boko Haram. The effects of the COVID-19 pandemic have exacerbated the humanitarian
need with the number of people estimated to be in urgent need of humanitarian assistance
rising since the outbreak began. The pandemic has further worsened inequities which has
posed major social and economic threats, with a devastating knock-on effect for the most
vulnerable population living in different settings experiencing varying effects of the COVID-19
pandemic.
To examine the social and economic impact of the COVID-19 pandemic amongst marginalised
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communities in Nigeria and assess the effectiveness of community-based interventions in
addressing inequities amongst IDP communities to guide future policy efforts.
A mixed-method approach was undertaken including key informant interviews alongside
desk review. Semi-structured interviews were carried out with vulnerable and marginalised
women of IDP camps and host communities to understand the direct and indirect impacts of
COVID-19 on their lives.
Key impacts of the COVID-19 pandemic were identied, including limited access to mitigation
methods, unmet health needs, impacts on livelihood, disruptions to education, food, markets,
and WASH facilities were also noted.
It is obvious that COVID-19 has negatively impacted the social and economic status of the host
communities and Internally Displaced Persons in Nigeria irrespective of their demographic
and location, there is need to trigger investment and behavioural changes that will reduce
the impact of future shocks and increase society’s resilience to these tragedies by focusing on
methods of prevention, stabilization, transformation, and sustainability to cater to the most
vulnerable populations.
1, Barbara Knittel1, Amanda Coile2, Annette Zou3 and Banny
Banerjee3, (1)JSI Research and Training Institute, Inc., Arlington, VA, (2)JSI Research and
Training Institute, Inc., Washington, DC, (3)Global Change Labs, Stanford, CA
Technical assistance (TA) in international aid has long been criticized for being poorly
coordinated, disempowering, shortsighted, self-interested, and not holistic or systematic in
solving public health challenges. While strengthened capacity is often an implicit or explicit
objective of TA, there is growing recognition that TA does not inherently contribute to capacity
strengthening and may actually undermine existing capacities or forge dependencies
on external support. The COVID-19 pandemic has spurred renewed interest in capacity
strengthening and TA — as primary mechanisms for global health aid — to foster country
ownership and support country institutions to lead their health agenda. However, despite
increasing rhetoric, operationalizing newer and better approaches for technical assistance are
limited.
The aim of this research was to interrogate systemic barriers to achieving more sustainable and
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
country-driven capacity strengthening models for global health aid. We co-created a vision
for improved donor support for capacity strengthening and used a system mapping process
to explore the interconnected ecosystem of partners and system behaviors that are impeding
progress. The process was based on Global ChangeLabs System Acupuncture® methodology
- an approach used to identify the critical change points in a system and develop innovative
interventions and actions to drive system-wide transformation. The system mapping was
informed by 1) previous re-imagining TA work in DRC and Nigeria, 2) rapid literature reviews,
including specic to gender inequities in health systems, 3) a co-creation system mapping
virtual workshop bringing together 40 participants from 12 countries, 4) semi-structured
interviews with 50 donor representatives and partners, and 5) monthly meetings and
discussion sessions with an inter-agency donor working group.
The co-creation process surfaced a set of nine key challenge areas (“Critical System Dynamics”)
that must be addressed in order to disrupt current failures in the global health aid ecosystem
and move towards the vision for improved capacity strengthening to achieve better health
outcomes. This work provides a new perspective on the systemic barriers and offers guidance
for donors and country decision makers to leverage in their strategy design and programmatic
decision making to move towards more system-aware approaches to health assistance.
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, University College Dublin, Ireland and Mwata L Chisha, University of
Lusaka, Zambia
As an increased number of the Coronavirus (Covid-19) cases crested over the East Africa
Community (EAC), member states redoubled their efforts to provide clear and austere
public health massaging to their citizens aimed at containing the virus. Using Rwanda as
case study, this paper contains an exploratory analysis of the government Covid-19 policy
messaging strategy, and its effectiveness in adherence to Covid-19 preventative measures.
Using a qualitative text analysis methodological approach, we analysed over a 3 months
period (December 2020 – February 2021) public documents and other Covid-19 government
messaging policy directives to explore the extent to which messaging carried a more nouned
impact on people’s adherence to preventative measure including wearing face-masks, social
distancing, reduction of employees at workplaces, and closures of publics places such as
schools and places of worship. This study found that the Rwandan government’s streamlined
lines of communication from the presidency through the ministries to the community was key
in delivering trusted public health messages, and this was found to have played a key role in
public adherence to government Covid-19 directives.
Covid-19, EAC, Rwanda, Business Management, Public Trust.
, Department of Health Policy, Planning & Management, Makerere
University School of Public Health, Angellah Irene Nakyanzi, ThinkWell Uganda, Kampala,
Uganda, Freddie Ssengooba, School of Public Health, College of Health Sciences, Makerere
University, Kampala, Uganda, Tapley Jordanwood, ThinkWell USA, Michael Chaitkin,
ThinkWell, Kampala, Uganda and Nirmala Ravishankar, ThinkWell USA, Mon Choisy, Mauritius
Like many countries, Uganda has decentralized responsibility for health service delivery.
The capacity of local governments to weather shocks and sustain health service delivery is
key. At the outset of the COVID-19 pandemic, the Government of Uganda (GoU) mobilised
funds to nance national- and district-level COVID-19 response activities. Effective resource
mobilization, allocation, and use is key to health system resilience during health emergencies,
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and much can be learned from the interactions between COVID-19 pandemic response and
public nancial management (PFM) systems.
This study assesses Uganda’s COVID-19 funding mechanisms, documenting health purchasing
arrangements and comparing the de jure versus de facto autonomy levels for scal and
operational decision-making by districts and health facilities. The study describes how
COVID-19 nancing evolved during the pandemic, with attention to how funds were mobilized
and used to pay providers, and how they were accounted for.
A cross sectional study was conducted across 43 health facilities in 8 districts. In-depth
interviews at the national level helped to clarify macro-level nancing and purchasing
decisions for COVID-19 and overall healthcare programs. Descriptive and comparative
statistics were calculated to show implementation progress, and qualitative data collected
through open-ended questions were analyzed using conventional content analysis (CCA) to
determine the pattern of nancial ows and spending priorities for COVID-19 interventions.
Supplementary information was extracted from relevant laws, policies, and guidelines that
govern the nancing of sub-national health services in Uganda.
This study determined the scal and operational autonomy sub-national governments and
facilities have within the public health system. Findings highlighted (1) how GoU and districts
mobilized resources to respond to the pandemic, (2) the evolution of rules and practices for
strategically purchasing during the pandemic and what opportunities were seized and missed,
and (3) lessons about vital adjustments in PFM especially during emergencies like COVID-19.
Lessons also related to the tensions between preparedness and escalated COVID-19 healthcare
and between public and private partnerships in nancing emergency response programs.
The COVID-19 pandemic prompted rapid efforts by the GoU to mobilize funds and channel
them to service providers. New approaches to purchasing emerged, prompting adjustments
to PFM practices. Uganda’s experience sheds light on whether health emergencies can
increase government willingness to grant greater scal and operational autonomy to local
governments and frontline facilities.
1, Peter B. Yaro2 and Adam Dokurugu2, (1)University for Development
Studies, School of Public Health, Department of Health Service, Policy, Planning, Management
and Economics, Tamale, Ghana, (2)BasicNeeds International, Tamale, Ghana
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
A resilient mental health system is paramount to the provision of quality mental health services
to everyone everywhere. However, the critical resources and nancial investment needed to
strengthen the mental health system in Ghana for better health outcomes remains a mirage.
Many vulnerable people with Mental, Neurological and Substance use (MNS) disorders who
needs care do not get the care they need, when they need it and where they need it.
The study aimed to investigate the resilience of the mental health system, access, delivery,
and sustainable nancing mechanisms at the primary care level for improved policy and
programme intervention for better mental health outcomes.
A cross-sectional exploratory qualitative study design was used for the study. Data were
collected through in-depth key informants’ interviews; complimented with observations,
in four districts of 3 regions from November -December 2019. A total of 44 key informants’
interviews were conducted: 4 District Directors of Health Services, 4 Regional Mental Health
Service Coordinators, 16 Mental Health Nurses, and 8 General Nurses, and 12 Mental Health
Caregivers. Qualitative data were coded and analyzed using thematic content analysis
approach and descriptive statistics. Desk review of published and grey literature were
also conducted and analyzed to compliment the eld data. were triangulated for
consistency and validity.
We found that mental health and neurological disorders services were highly stigmatized,
neglected in funding, infrastructure, human and material resources at all levels of care, as
compared to the other services of the health care system. Funding support of mental health
services by the Districts, Municipal and Metropolitan Assemblies were highly insignicant.
Religious bodies and Non-governmental Organizations (NGOs) played a very important role in
funding mental health services at the community level.
The mental health System in Ghana is very weak in funding, human resources, and inequities
in the distribution of resources are pervasive. Mental health services are almost neglected,
and stigmatization of mental illness, and mental health personnel is rife. We recommend that
Government should partner with the private sector to prioritize and strengthen mental health
service in Ghana, through health promotion, education, and adequate earmarked funding.
Access, Delivery, Ghana, Mental Health System, Funding, Stigmatization,
Resilience.
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, National Institute for Legislative and Democratic Studies, National
Assembly, Abuja, Nigeria
The advent of COVID-19 pandemic has put Governments across Africa under pressure to
reinforce measures to contain the spread of COVID-19, fearing that Africa fragile health systems
will become too overwhelmed if the disease spreads uncontrollably which will further worsen
the socioeconomic lives of the people. As part of the lessons learnt in Nigeria, health system
strengthening and emergency funding for pandemic is key to achieving health system
resilience to enable the country prepare towards tackling the present and future pandemics.
Although the establishment of Nigerian Center for Disease control (NCDC) in 2018 to Prevent,
detect, and control diseases of public health importance is a step in the right direction, it is
essential to act and make the necessary investments nationwide to establish a strong and
resilient health system that can respond effectively to future health emergencies, absorb
shocks, and adapt to changing health demands.
The objective of the paper is to identify and discuss health system strengthening and
emergency funding gaps that must be considered to attain Nigerian health system resilience
that can tackle the present and future pandemic. Specically, the paper seeks to;
1. Discuss health system resilience in the context of the Nigerian health sector
2. Identify and discuss the Nigerian health system strengthening and emergency funding
gaps in the context of health system resilience
3. Identify and discuss steps to building a resilient health system in Nigeria
The paper specically adopts content analysis and systematic review. Content analysis and
systematic review also entails analysis of cross-country experience of policies in achieving
health system strengthening and sources of covid-19 emergency funding.
The study shows that the major health system strengthening gaps is embedded in inability of
the health system to achieve development in the six building blocks that is typical of a resilient
health system. These include; health information, health workforce, essential medicines, health
systems nancing and leadership and governance. There is emergency funding gap as 5%
of Basic Health Care Provision Funds (BHCPF) allocated for emergency is not sufcient and
access to the fund is a major problem due to bureaucracy and lack of implementation of the
BHCPF
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
The study concludes that investment in the development of the six building blocks of the
health system will ll the health system strengthening gap. Innovative health nancing can
also leverage on emergency funding to meet the health system funding gap.
, London School of Economics, Oxford, United Kingdom
The COVID-19 pandemic has brought about a spike in the demand for healthcare services and
most countries are struggling with their capacity to maintain the delivery of essential health
services while trying to respond to testing, tracing and treatment and delivering COVID-19
vaccines. Government alone can not handle this crisis alone. A fully mobilized and organized
range of health system actors - in both the public and private sector needs to keep health
systems working.
Examine the level of Public and private sector collaboration to maintain a functional
healthcare system in response to the COVID-19 pandemic
This study focused on Nigeria and a qualitative method was used, which
includes: conducting an initial desk review to understand the existing mechanisms for public
and private sector engagement, reviewing scientic publications, program technical reports
and grey literature, this was further complemented with semi-structured key informant
interviews with healthcare stakeholders working in the public and private sectors. Interview
transcripts were analysed thematically using Atlas ti qualitative data analysis software package.
The public and private sectors collaborated in many ways to mount a strong
response to tackle the COVID-19 pandemic in Nigeria at National and sub-national levels. The
private sectors complemented the Government’s programs by carrying out key activities to
tackle COVID-19 which includes the development of rapid diagnostic kits, health workforce
training, disease surveillance, reporting, nancial support etc.
Multi-sectoral collaboration between the public and private healthcare stakeholders was found
to be very useful towards mobilising Financial and Human resources while responding to the
sudden effects of the COVID-19 pandemic on the health systems and maintaining the delivery
of essential healthcare services. However, a well structured public and private sector dialogue
and engagement mechanism needs to be institutionalised to enable the Government to
provide the required oversight and stewardship to enable the private sector to deliver quality
and affordable healthcare services towards responding to future health emergencies and
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achieving Universal Healthcare Coverage for all by 2030.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Ivy Osei1, Dr. Ama Pokuaa Fenny, PhD2, Tamara Chikhradze3, Alphonse
Dzakpasu4 and Elizabeth Hammah5, (1)Ghana Health Service, Accra, Ghana, (2)Institute
of Statistical, Social and Economic Research, Accra, Ghana, (3)Results for Development,
Washington, DC, (4)Peki Government Hospital, Ghana, (5)Results for Development, Accra,
Ghana
Equity is essential for achieving the Universal Health Coverage. Primary Care Provider (PCP)
Networks are an innovative service delivery model designed to promote equitable access to
Primary Health Care (PHC) services within the Community-based Health Planning and Services
(CHPS) in Ghana.
Implementation research explored the role of PCP Networks in advancing equity, especially
among the poor, women, and residents in rural or hard to reach areas.
The study used mixed methods and was conducted in South Dayi and South Tongu districts.
500 randomly selected households were surveyed. Findings were disaggregated by household
wealth – measured by the Equity Tool - gender of the household head and household location.
Categorical variables were cross tabulated and Chi-squared tests were used to investigate
signicant differences of all variables relative to household characteristics. Multi-variate
regression analysis was done to estimate the effect of different factors on utilization of care.
Qualitative methodology included 14 focus group discussions and 17 in-depth interviews
with community members, PCP Network practitioners and managers. Thematic analysis was
employed.
Majority (88.4%) of households where a member reported illness or injury sought care in a
facility, but only 3.9% of these visited CHPS. Members of the wealthiest households were 1.4
times more likely to visit a facility than the poorest ones. 48% of the households in the highest
quintile traveled <1km to the health facility compared to 20% of households in the lowest
quintile. 45.3% of Urban households travelled <1km compared to only 21.8% of rural ones.
These ndings were supported by the qualitative results, where respondents noted preference
for higher level facilities. Improvements in service delivery practices were noted by Network
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practitioners and managers, mainly through resource-sharing, improved teamwork, joint
outreach, and collaboration on referrals among Networks. But respondents also highlighted
factors that likely prohibit the Networks from promoting equity, including some quality
variables such as the availability of drugs, supplies, infrastructure, insurance at CHPS, and
absence of transport options. Networks should engage strategically with communities, local
government, and private sector to alleviate some of these barriers.
Patterns and preferences of health service in districts are inconsistent with the Networks’
equity enhancing efforts, and various demand and supply side factors inhibit PCP Networks
from successfully implementing equity enhancing practices. Future research should focus on
the role Networks can play in improving service availability and quality – as key factors in their
ability to promote equitable PHC.
, Stellenbosch University, Stellenbosch, South Africa
Treatment variation has implications for patient outcomes and costs, both of which are vital
for funders to understand as healthcare systems move towards value-based contracting.
Developing value-based contracting is important in South Africa as the country plans to
implement a National Health Insurance (NHI). Currently, practitioners in the South African
private sector have discretion in how they treat patients with spinal pathologies which results
in signicant treatment variation. There is no formal monitoring and reporting of health
outcomes that is necessary to assess if the various practitioners’ treatment decisions improve
patient outcomes.
To assess treatment variation of various spine pathologies in South Africa through
investigating supply side factors including surgeon characteristics that inuence surgeons’
treatment decisions
We conducted a survey with four vignettes of spine surgeons. We summarize surgeon
characteristics and calculate the Index of Qualitative Variation (IQV) to determine the degree
of variability within each of the four vignettes. We provide two-way tables with Pearson
Chi-square statistic to test signicance. Statistically signicant variables were included in
regression analyses. We compare survey responses to the recommendations from a panel
of spinal surgeon specialists. Then, because healthcare systems are moving towards value-
based contracting, we introduce a cost component to illustrate the nancial implication of the
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treatment variation.
Surgeons selections on treatment options varied for each of the vignettes. Vignettes 1 and
4 have high levels of variability with IQVs above 0.75. Four surgeon characteristics were
signicant in at least one of the vignettes: number of surgeries per month, designated service
providers, length in practice and university. These characteristics remained signicant in the
subsequent regression analyses. Surgeons did not consistently select the Panel’s preferred
treatment options and 19% of the surgeons selected treatment options that the panel did
not think were suitable for one of the four vignettes. Analysis of costs revealed large nancial
implications between conservative and procedural treatments.
The variation in ndings is unsurprising given the lack of clear guidelines for spinal pathology.
It provides a strong case to move towards improving and implementing outcomes reporting
and value-based reporting. This will help to identify care that is less effective and steer
surgeons to evidence based treatment that provides value to the patient and funder. This is
necessary as the government develops the NHI packages.
1, Cathbert Tumusiime2, Richard Ssemujju2, Dennis Senyonjo3 and Daniel Ayen
Okello3, (1)Kampala Capital City Authority, Uganda, City Hall, Uganda, (2)ThinkWell Uganda,
Kampala, Uganda, (3)Kampala Capital City Authority, Uganda
Sub-national governments throughout Uganda receive daily COVID-19 case alerts from the
Ministry of Health. The Kampala Capital City Authority (KCCA) is responsible for the health of
4.5 million people who are either residents or daily commuters into the city from surrounding
districts. To effectively manage case alert data and response activities, the KCCA developed
a City Health Information System (CHIS) to support case investigation, contact tracing, and
strategic re-deployment of scarce health system resources.
This study describes the development of a new health information system for pandemic
response in Uganda’s largest urban area. With a focus on the rst nine months of the
pandemic, it unpacks the motivations for deploying the CHIS, its relationship to incumbent
systems (e.g., DHIS2), and the process for dening indicators and data elements. It also
examines the role the CHIS played in response management and resource allocation decision-
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
making. Finally, it identies lessons for responding to future health emergencies in urban
areas.
All data came from ofcial policy documents and the authors’ recollections and personal
records. All contributing authors were directly involved in the design, implementation, and use
of the CHIS in their capacity as government ofcials and partners.
The CHIS was developed to augment existing health management information systems,
whose data were insufciently granular to support effective coordination of surveillance and
response activities across the Kampala metropolitan area. Consultations with health system
stakeholders informed the denition of key indicators, which were aligned with the national
and city pandemic response plans. Implementation required training of surveillance teams
and regular data quality assessments. As the pandemic progressed, several KCCA bodies came
to rely on the CHIS for their operations and decision-making. District and site-linked case data
enabled the real-time identication of hotspots and re-deployment of key resources, such as
personnel and vehicles, to address them. The CHIS became a key platform for coordinating and
tracking case investigation, contact tracing, and patient evacuation activities.
The CHIS greatly improved access to and use of real-time data to inform decision-making
for the COVID-19 response throughout the Kampala metropolitan area. Evidence from the
CHIS guided operations and informed key policies, such as the imposition and later easing
of lockdowns. Efforts are ongoing to harmonize the CHIS with national information systems.
Other urban areas spanning multiple jurisdictions could similarly benet from tailored
information systems for pandemic response.
1, Angellah Irene Nakyanzi2, Richard Ssemujju2, Ivan Onyutta1 and
Michael Chaitkin3, (1)Uganda Healthcare Federation, (2)ThinkWell Uganda, Kampala, Uganda,
(3)ThinkWell, Kampala, Uganda
Historically, engagement between Uganda’s public and private health sectors has generally
been modest and informal. Although policy frameworks and forums exist for public-
private partnerships in health, they have not consistently yielded sustained collaboration
in the planning, nancing, or delivery of health services. Nonetheless, early in the COVID-19
pandemic, both government and private sector actors recognized the potential value of
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partnerships to the national response. To bolster the country’s multi-sectoral approach
to pandemic response, the public and private sectors developed new modalities for joint
planning, policy framing, and implementation.
This study examines and documents the role of Uganda’s private sector within the country’s
multi-sectoral approach to COVID-19. It describes the process of private sector engagement
by the government and the key roles of private actors in mobilizing their sector and putting in
place new policy frameworks to strengthen future responses.
The roles played by private sector health system actors in the COVID-19 response were
determined through purposeful review of government policies and pandemic response
reports, complemented with consultations with Ministry of Health (MOH) ofcials, prominent
private sector bodies, and national and district COVID-19 task force members.
Since March 2020, private sector actors have heeded to the Ofce of the Prime Minister’s call to
support Uganda’s pandemic response. In partnership with the Kampala Capital City Authority
(KCCA), the Uganda Healthcare Federation (UHF), a private sector umbrella organisation,
mobilized and capacitated private providers to augment the strained public health system for
COVID-19 case management in the country’s largest urban area. More recently, in anticipation
of vaccine availability and to formalize public-private collaboration, the multi-stakeholder
national COVID-19 task force developed the Ugandan Framework and Guidelines for Private
Sector Inclusion in the COVID-19 Vaccination National Response. Extensive policy reviews and
consultations, led by the UHF and ThinkWell, were key to the framework’s design. Its adoption
marked an unprecedented commitment to multi-sectoral partnerships among the MOH,
pharmaceutical companies, private providers, distributors, associations, and more.
The partnerships formed in the COVID-19 response have fostered solidarity and collaboration
for current and planned public health interventions. Private sector contributions are
especially important to expanding equitable vaccine access, maintaining cold chain integrity,
and surveillance. Recognizing the place of the private sector, government should identify
mechanisms to leverage private sector actors both in ensuring the continuity of essential non-
COVID-19 services and supporting national responses to future pandemics.
1, Hyacinthe Mushumbamwiza2, Siyabonga Ndwandwe2, Moyo Butholenkosi2,
Regis Hitimana3, Jason Houdek4, Damien Kirchhoffer4, Logan Brenzel5, Donatien Bajyanama6,
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Zuberi Muvunyi6 and Corneille Ntihabose6, (1)United Nations Children Fund (UNICEF), Nairobi,
Kenya, (2)Clinton Health Access (CHAI), Kigali, Rwanda, (3)Rwanda Social Security Board
(RSSB), Kigali, Rwanda, (4)Clinton Health Access (CHAI), Boston, (5)Bill & Melinda Gates
Foundation, (6)Ministry of Health, Kigali, Rwanda
Medical oxygen therapy is core in treatment of respiratory illnesses including advanced
COVID-19. In public hospitals across Low-Income Countries, supply systems operate sub-
optimally due to limited production, irregular plant maintenance and sub-optimal oxygen
prices. Rwandan hospitals are reimbursed through health insurance schemes for oxygen
consumption of their patients, for which there is a single tariff. While procured by price in
volumes, hospital reimbursement claims for oxygen are calculated by hours of use, and
not volumes used (cylinders or liters). During utilization, oxygen consumption is recorded
at an hourly rate to reect the average tariff paid per hour. This research explored whether
the current tariff rates allowed for hospitals to break even, given different oxygen owrates
required to treat various medical conditions. It also modelled tariff scenarios that could
optimize the provision of oxygen therapies.
Records for 37,809 non Covid patients in 25 hospitals, between June 2019 and June 2020, were
used to estimate oxygen therapy utilization across different wards (average of 9 wards per
hospital). These included 20 District Hospitals, 4 Referral Hospitals and 1 Provincial Hospital. The
duration of treatment and average owrate, as recommended by clinical guidelines, was used
to estimate total oxygen consumed per patient, and nancial implications on hospitals were
estimated based on their revenue and total oxygen procurement costs. Analysis of the records
showed median ow rate was approximately 10L/min with the upper quartile having a wider
variation of ow rates, and the average duration on oxygen therapy was 50 hours per patient.
The model developed considers both therapy duration and volume of oxygen used during the
therapy, minimizing the marginal revenue obtained at lower ow rates and the loss obtained
while using high ow rates. This almost guarantees that hospitals will not operate at a loss
while also reducing liability to the insurance company for therapies requiring low ow rates.
(1) Oxygen tariffs should be inuenced by the volume of oxygen administered to specic
patient types as an initial step to harmonize them. (2) More ideal would be to switch to a
volume-based tariff. This analysis informs policy makers on the link between prices and
utilization of oxygen therapy, and the important linkage of consumption to patients’ oxygen
owrate requirements. Accurate oxygen ow administration (LPM), and the use of pulse
oximeters help regulate the oxygen ow as patients stabilize; practices that need to be
improved to control effective utilization and in effect costs.
, Centre de Connaissances en Santé en RD. Congo, KINSHASA, Congo (The
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Democratic Republic of the)
Since December 2019, the world has been facing an emerging disease, Covid-19, declared a
pandemic by the WHO on 01/30/2020. The DRC recorded its rst case in March 2020. Since
then, many measures have been taken to control the epidemic.
The objective of this study is to identify the main response measures taken during this
pandemic in the DRC and to analyze them in terms of who took them, why, how and where.
This is a case study on the ght against Covid-19 in the DRC. The documentary review
and the semi-structured interviews of the key informants (face to face, by telephone or by
videoconference) made it possible to collect data.
Once the epidemic was declared, national authorities took measures to control this rst
wave: 14-day quarantine of travelers from countries affected by Covid-19; suspension of ights
from affected countries; implementation of control measures. A technical secretariat and a
presidential task force composed of scientists have been set up to help the authorities make
decisions informed by the evidence. Thus, to limit the spread of the epidemic, the President
of the Republic has decreed a state of health emergency: travel ban, closure of schools
and universities, etc. (from March 24 to July 21, 2020) combined with individual prevention
measures (correct wearing of masks, hand washing, physical distancing). For its part, the
technical secretariat has adopted, based on the results of certain observational studies,
a therapeutic protocol combining Chloroquine with Azithromycin. In Kinshasa, the initial
epicenter of the epidemic, the increase in cases and their concentration in the commune of
Gombe had led the governor to decree from April 06 to June 29, 2020, the connement of
this commune to limit the spread of epidemic. In December 2020, during the 2nd wave, the
President decreed a national curfew still in effect. The agship measure during the 3rd wave
remains vaccination against Covid-19 in the most affected cities.
During successive waves, measures were taken to control the epidemic. But some have had
signicant collateral effects on the daily lives of the population. Their application in the future
requires a balance between the desired effectiveness and the undesirable collateral effects on
the population.
Mesures de contrôle, Covid-19, RDC
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
1, Kasarachi Omitiran2, Okikiolu Badejo3, Achama Eluwa4, Felix
Obi5, Adaobi Ezeokoli6, Nneka Orji7, Ugochi Odu8, Chukwunonso Umeh9, Rosemary Nnabude5,
Dr. Frances Ilika10, Adaeze Oreh5 and Ejemai Eboreime11, (1)Doctorkk Health International,
Lagos, Nigeria, (2)Department of Community Health Services, National Primary Health Care
Development Agency, Abuja, Nigeria, (3)Department of Public Health, Institute of Tropical
Medicine, Antwerp, Belgium, (4)Nufeld Department of Medicine, University of Oxford, Oxford,
United Kingdom, (5)Systems Development Initiative, Abuja, Nigeria, (6)Nigeria Health Watch,
Abuja, Nigeria, (7)Department of Health Planning, Research and Statistics, Federal Ministry
of Health, Abuja, Nigeria, (8)Healthreach Limited, Abuja, Nigeria, (9)Africa Resource Center
for Excellence in Supply Chain Management, Abuja, Nigeria, (10)USAID Health Policy Plus
(HP+) Project of Palladium International Development Company – Abuja, Abuja, Nigeria, (11)
Department of Psychiatry, University of Alberta, Edmonton, Canada
The practice of utilization of evidence from research ndings in formulating health policy by
stakeholders in Nigeria is relatively minimal. This may be attributable to relative insufcient
capacity to generate and utilize health policy and systems research (HPSR) ndings. The
of the consortium of stakeholders in Nigeria supported by the Health Systems Global African
forum, which organized a virtual convening for key local stakeholders, was to engage
stakeholders to collaboratively identify gaps, opportunities, as well as develop strategies and
tools to improve the use of evidence in health policy making.
The convening was a 2-day virtual participant-driven conference which held in August 2020.
The participants included health and political policy makers, researchers, philanthropists,
global health practitioners, the media, civil society and other stakeholder groups. Various
formats were combined for effective participation and deliberation on issues including plenary
sessions, panel discussions led by seasoned practitioners, academics and policy makers vast
in the eld of HPSR, as well as question and answer sessions after each panel discussion.
The outcomes were shared with stakeholders through policy briefs, advocacy sessions and
publications.
Gaps identied include poor funding of context-specic health systems research and
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
capacity building, gender inequality in evidence generation and decision making, poor
multi-sectoral collaboration, weak health nancing policies, ineffective mechanisms of
knowledge translation, and poor utilization of research ndings by policy makers. Other gaps
that were found included poor linkages between researchers, policy makers, implementers
and beneciary communities/groups. Others were absence or minimal co-creation or co-
production in research design especially non-involvement of beneciaries. Recommendations
provided include multi-sectoral approach to problem solving, country ownership and
development of concrete research agenda that is informed by the society, focusing research
questions on the right places and the right people, including gender analysis in HPSR in order
to promote gender equity and building interpersonal relationships in order to strengthen the
relationship among researchers, policy makers and practitioners.
The stakeholder convening provided a forum for open discussions on key gaps and potential
mitigating strategies in evidence-informed policy making. The broad bottom-up approach
employed provided realistic opinions to be tested and employed to improve evidence
generation and utilization. Lessons learned from this engagement can be adopted in similar
contexts across sub-Saharan Africa and beyond.
1, Brendan Kwesiga2, Doris Osei Afriyie3, Hillary Kipruto4 and Humphrey
Karamagi1, (1)WHO Regional Ofce for Africa, Brazzaville, Congo, (2)WHO Kenya Country
Ofce, Nairobi, Kenya, (3)Department of Epidemiology and Public Health, Swiss Tropical
and Public Health Institute, Basel, Switzerland, (4)World Health Organization, Inter-Country
Support Team for Eastern & Southern Africa, Harare, Zimbabwe
While African countries have committed to the goal of Universal Health Coverage, it is critical
that the improvements in both coverage and nancial risk protection are equitably distributed
across the population. Policy markers within the African region need to not only understand
the extent of inequality but also factors that explain the observed inequality. This study set
out to measure and explain the extent of socio-economic inequality across essential health
services key to the attainment of Universal Health coverage.
This study set out to measure and explain the extent of socio-economic inequality across
essential health services key to the attainment of Universal Health coverage.
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Data for the analysis was obtained from nationally representative samples from Demographic
and Health Surveys for countries in the region. Socio-economic status is measured using
a wealth index generated through principal component analysis UHC Service Coverage
indicators were adopted from the WHO UHC Service Coverage Index. Indicators span the
service-related sub-indices of the UHC index namely, reproductive and maternal health
services, infectious diseases and non-communicable diseases. The concentration indices
for these three service areas were used as the primary measure of inequality and they were
decomposed into their determining factors using a generalized linear model with binomial
logit link.
Across the 47 countries included in the analysis, coverage for reproductive and maternal
health services, infectious diseases and non-communicable diseases demonstrated pro-rich
inequality. The largest contributions to inequality were driven by education, health insurance
coverage and socio-economic status. Urban/Rural divide was also important contributors in
the measured inequality of all four services.
The ndings indicate that inequality remains an important challenge for attainment of UHC
in Africa. Although actions will be needed within the health sector to address this challenge,
multisectoral investments beyond the scope of the health sector especially the education
sector will also need to be addressed.
1, Glory-Anne Leaupepe2, Stephen Birch2, Francis Ruiz3, Emmanuel
Ankrah Odame4 and Justice Nonvignon5, (1)Kwame Nkrumah University of Science and
Technology, Kumasi, Ghana, (2)University of Queensland, Brisbane, QLD, Australia, (3)London
School of Hygiene & Tropical Medicine, London, United Kingdom, (4)Ministry of Health Ghana,
Accra, Ghana, (5)Department of Health Policy, Planning and Management, School of Public
Health, University of Ghana, Legon, Ghana
Decision-makers in sub-Saharan Africa (SSA) faced unprecedented challenges during the
Covid-19 pandemic to make decisions to allocate health resources in the face of scarce
resources together with constrained data availability and quality. Despite the appropriate focus
on the pandemic, the burden of non-communicable diseases (NCD) increasingly needs more
attention. Economic evaluations can help to determine which health interventions should be
funded or included in any universal health care (UHC) benets package. The data and sources
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Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
for these analyses need to reliable and relevant to the country of interest.
To describe the aspects of economic evaluations and assess the quality of the data sources
used in all published economic evaluations relevant to two NCD in SSA.
We systematically searched selected databases (PubMed, EMBASE, CINAHL, Scopus) for all
published economic evaluations for cardiovascular disease and diabetes in SSA. We screened
studies and extracted data using the iDSI reference case with 11 principles (e.g. evidence,
health outcomes, costs) to measure the adherence of studies to reporting (score of 21) and
methodological aspects (score of 19). We assessed and described the quality of data sources
using a hierarchical scoring system.
From 7,297 retrieved articles, we selected 35 studies; most focused on medicines. Half the
studies (51%) had rst authors based in Africa, most were from a single country (83%), had
a utility-linked outcome (e.g. DALY or QALY, 69%), were either cost-effectiveness (or utility)
analysis (80%), had an analytical model (71%), took a health care system perspective (60%), and
used a threshold measure related to Gross Domestic Product (57%). Adherence to reporting
aspects was higher (mean 81%, average 17/21, ve had perfect scores) than adherence
to methodological aspects (mean 67%, average 13/19). The strongest areas concerned
transparency, comparators, and evidence but the weakest areas were uncertainty, budget
impact, and equity. Data sources - and their quality - were various and included both locally-
derived sources and international databases (e.g. WHO).
While many economic evaluations were of high quality, there is room to improve the sources
and quality of data integral to analyses in SSA. We need more information on budget impact
and equity considerations. A politically-supported and sustained focus on developing and
maintaining reliable and locally-relevant data sources (perhaps with a regional approach)
will lead to better evidence to support decision making in SSA within the context of UHC and
health benets plans and resilient health systems.
, Ronelle Burger and Marisa von Fintel, Department of Economics,
Stellenbosch University, Stellenbosch, South Africa
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Following the outbreak of COVID-19 towards the end of 2019, South Africa, like most
countries, was placed in a full national lockdown in March 2020, and economic, physical,
and entertainment activities and mobility were severely restrained in an effort to contain
the pandemic. Given differences in socioeconomic statuses, individuals’ coping abilities in
the face of the threat of exposure to the virus and its consequences differ. Current evidence
suggests that the pandemic and related public health measures instituted to slow down the
spread of COVID-19 have worsened existing inequalities, with the burden of the pandemic
being disproportionately borne by the vulnerable. However, there is literature that suggest
that shocks like pandemics, wars, and civil conicts narrow inequalities. Be that as it may, the
economic impacts of COVID-19 containment measures will affect the incidence, prevalence,
and distribution of mental ill health, now and for years to come.
The present study was aimed at ascertaining the impact of the COVID-19 pandemic on
income-related inequality in mental health in South Africa, which is a highly unequal middle-
income country.
Data used were drawn from the last three rounds of the South African National Income
Dynamics Survey (NIDS) and the fth round of the NIDS-Coronavirus Rapid Mobile Survey
(NIDS-CRAM). The recentred inuence functions (RIF) regression decomposition method was
employed to ascertain the inuence of the COVID-19 pandemic on inequality in depressive
symptoms related to per capita household income in South Africa. Health. Depressive
symptoms were screened using the 10-item Centre for Epidemiological Studies Depression
Scale (CESD-10) (Radloff, 1977) in the NIDS and the Patient Health Questionnaire (PHQ-2)
(Kroenke, Spitzer & Williams, 2003) in the NIDS-CRAM.
We found that the distribution of good mental health was pro-rich before and during the
pandemic. We also found that the COVID-19 pandemic has signicantly less inuence
on income-related mental health inequality when measured using the shortfall relative
concentration index and the Wagstaff index, but not when measured using the Erreygers
index or the attainment relative concentration index.
Although the positive association between good mental health and afuence remains, the
COVID-19 pandemic increases mental health problems amongst the afuent. The developing
mental health effects of the COVID-19 pandemic can be offset by tractable policy measures to
reduce historical inequalities.
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Felix Houphouet University Boigny Abidjan Cocody boigny, ABIDJAN,
Côte d’Ivoire
Universal health coverage (UHC) is a key element of Côte d’Ivoire’s health policy. Although
health outcomes have improved over the past decade, signicant inequalities remain.
However, some of its indicators are among the highest in West Africa and its health service
coverage is stronger than many low-income countries. Developing a policy to provide access to
health care for all Ivorians requires identifying barriers to access, as well as the characteristics of
non-users.
The study explores the 2019 and 2020 Household Living Conditions Surveys. We use Benet
Incidence Analysis (BIA) to determine the use of different health services by socio-economic
group. Logistic regressions are also used to identify correlations between access to care and
the incidence of Catastrophic Health Expenditure (CHE). The regression analysis identies the
determinants of household vulnerability to CHD by geographic and socio-economic variables.
The IYB indicates that only mobile clinics and community health worker interventions benet
the poor. Although typically in rural areas, clinics do not benet the poor.
The main reason for low utilisation of services is that they are not affordable. In 2019, 27 per
cent of households reported not seeking health care despite being ill. Of these, 48 per cent
said they did not seek care because the price was too high. For the lowest wealth quintile, this
gure was 67%.
Use of services varies by education, wealth and department. Households in the wealthiest
quintile used 2.6 times more health services than those in the least wealthy quintile. The latter
face less DCS compared to the richest quintile as they forego care.
This paper presents new elements and opportunities for Côte d’Ivoire to achieve UHC. Côte
d’Ivoire needs to: 1) prioritise pro-poor policies, including the provision of an essential package
of services at the primary level, 2) strengthen pro-poor programmes such as mobile clinics, and
3) target rural populations. This should be complemented by strategies to waive or reduce fees
for the poor but this requires strong coordination between public, private and NGO providers.
6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Akissi Régine Attia Konan¹, Kouame Kof², Jerome Kouame², Momine Felix Male³, Adama
Sanogo Pongathie³ and Stéphane Serge Agbaya Oga², (1) University of Felix Houphouët
Boigny, Abidjan, Côte d’Ivoire, (2) UNIVERSITY OF F H BOIGNY, ABIDJAN, Côte d’Ivoire, (3)
Department of Computer Science and Health Information, Abidjan, Côte d’Ivoire
Free health care policies have been adopted in many countries in sub-Saharan Africa to
remove nancial barriers to accessing health services. These policies target vulnerable
populations such as pregnant women and children aged 0-5 years. In Côte d’Ivoire, a policy
of free health care for pregnant women has been in force since April 2012 in order to improve
maternal mortality indicators. This study aims to document the effects of the abolition of fees
on the use of health services in Côte d’Ivoire. It aims to assess the effects of free care among
pregnant women from 2011 to 2020.
This is a longitudinal study with a descriptive aim over 11 years (2010 to 2020). Data were
obtained from the national DHIS2 information system and the SIGL supply chain management
software. Data on the availability of free tracer drugs for the year 2020 and on the use of ANC
consultation services (1st and 4th ANC) were extracted from the different databases as well as
the number of health facilities within 5 km and the ratios of health personnel/population.
An increase in the number of NPC1 and NPC4 was observed over the period averaging 6.2%
and 5.5% respectively. NICU and ANC4 coverage increased by an average of 4.4% and 8.5%
respectively. However, the ANC drop-out rate remained stable over the 11 years with an
average of 59.3%. The number of women who performed their rst ANC in the rst trimester
of pregnancy represented half of all ANC1 recorded in 2010. The availability of drugs for the
mother-child programme was estimated at 52.5% in 2020, while that of all health products was
56%. The ratio of health workers to the population has been in line with the WHO standard
since 2017. On average, 70% of the population lived within 5 km of a health facility.
Despite the fee exemption measure, women do not follow the ANC recommendations of the
mother-child programme. The causes of non-adherence need to be documented in order to
improve the levels of use of maternal health services.
Pregnant woman, Antenatal consultations, Universal health coverage, Côte d’Ivoire
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
, Consultant indépendant, Ouagadougou, Burkina Faso, Jean-Claude Wema,
Consultant indépendant, Thomas Engels, Oeconomia-Expertise, Ed Vreeke, hera and
Elisabeth Paul, Université Libre de Bruxelles
The health nancing system in the province of South Kivu is still characterised by a lack of
resources and an almost non-existent and irregular contribution from the state. This context
remains unfavourable to the achievement of Universal Health Coverage in the province (UHC).
Through operational research, this study maps and evaluates existing health nancing
mechanisms with a view to drawing lessons for reforming the nancing of the provincial
health system in South Kivu and moving towards UHC.
The results indicate that health nancing remains fragmented and characterised by a
multitude of actors deploying insufciently harmonised and coordinated interventions.
Cost recovery and external support to strengthen the health system are the most common
nancing approaches used in the province. The development of mutual health insurance
schemes can contribute to improving access to health care for the population, even if their
coverage rates remain extremely low. Results-based nancing (RBF) and free care, nanced
mainly by technical and nancial partners, are irregular and insufciently sustainable.
In view of this situation, it is suggested that an integrated strategic purchasing model be
adopted: i) anchored in local institutions, ii) appropriate for all stakeholders and, iii) focused on
joint implementation of mutual health insurance, free care, RBF and cost recovery for the most
afuent. It is also recommended to set up a support fund for the provincial health system in
order to strengthen the mobilisation and pooling of foreign support and budget resources.
Finally, it is proposed to operationalise the “Single Contract” initiative with a view to
harmonising, pooling and ensuring the sustainability of the partners’ support programmes for
the province. This operationalisation will involve: i) strengthening policy dialogue, ii) developing
an investment case to be used as an advocacy tool for resource mobilisation, and iii) creating a
platform for regular monitoring and evaluation of nancial commitments and disbursements
under the leadership of provincial health authorities.
, Félix Houphouët University Boigny, Abidjan, Côte d’Ivoire
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6th Biennial Scientic Conference of the African Health Economics and Policy Association (AfHEA)
Theme: Towards Resilient Health Systems in Africa: The Role of Health Economics and Policy Research.
Since the Covid 19 health crisis in 2020 following the Alma Ata Declaration of 1978, equity in
access to health care services has become an important political concern for all nation states.
The objective is to analyse health nancing by households. More specically, the aim is to
analyse the extent of out-of-pocket payments and their determinants in relation to the
challenges facing health nancing policy in Burkina Faso.
We use the ability-to-pay approach at the 10%, 25% and 40% thresholds recommended by the
Sustainable Development Goals (SDGs) and the World Health Organization (WHO). The data
come from the Harmonized Survey on Living Conditions of Households (EHCVM) of the West
African Economic and Monetary Union (UEMOA), 2018 edition 1 of Burkina Faso; and cover
7,010 households for the statistical analysis and 6,460 households for the regression by the
probit model.
The magnitude of catastrophic care expenditure decreases as the threshold increases from
5% to 40% with an amplitude of 5%. It varies from 10.29% to 0.66% in incidence and 1.13% to
0.28% in intensity respectively. Households spend 15.98% to 83.61% of their ability to pay on
health care. Its determinants are: wealth, age, marital status, household size, education level
and industry. The gender approach to the determinants conrms almost the same results. It
supports the adage that “poverty has a female face”. For the few women who are exempted
from exorbitant expenses, this depends mainly on their own bargaining power with their
spouses, the education level of their spouses, the region of residence and/or the ethnic origin
of their spouses.
A better targeting of health nancing policies for all in Burkina Faso can be envisaged by
starting with the sensitisation of households to join the Universal Health Insurance (UHI) as
well as the sensitisation to maintain their healthy living environment.
equity, direct payments, gender, Universal Health Insurance.
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