Research Articles
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A research article reports the results of original research, assesses its contribution to the body of knowledge in a given area, and is published in a peer-reviewed scholarly journal. The faculty publications through published and on-going articles/researches are captured in this community
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Item What are the Technical and Allocative Efficiencies of Public Health Centres in Ghana?(Ghana Medical Journal, 2008-12) Akazili, J.; Adjuik, M.; Chatio, S.; Kanyomse, E.; Hodgson, A.; Aikins, M.; Gyapong, J.Introduction: Health systems in developing countries including Ghana are faced with critical resource constraints in pursuing the goal of improving the health status of the population. The constrained ability to adequately meet health care needs is exacerbated by inefficiency in the health care systems, especially within public health centres. Methods: The study used Data Envelopment Analysis (DEA) method, to calculate the technical and allocative efficiency of 113 randomly sampled health centres. A logistic regression model was also applied on whether a health centre was technically efficient or not to determine the factors that significantly influence the efficiency of health centres. Findings: The findings showed that 78% of health centres were technically inefficient and so were using resources that they did not actually need. Eight-eight percent were also allocatively inefficient. The overall efficiency, (product of the technical and allocative efficiency), was also calculated and over 90% of the health centres were inefficient. The results of a logistic regression analysis show that newer health centres and those which receive incentives were more likely to be technically efficient compared to older health centres and those who did receive incentives. Conclusion: The results broadly point to grave inefficiency in the health care delivery system of the health centres and that lots of resources could be saved if measures were put in place to curb the waste. Incentives to health centres were found to be major motivating factors to the promotion of efficiency.Item Working practices and incomes of health workers: evidence from an evaluation of a delivery fee exemption scheme in Ghana(2007-01-22) Witter, S.; Kusi, A.; Aikins, M.Abstract Background This article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana. Methods A structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained. Results Health workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client – $1.09 – is similar to a nurse's (and lower than a private midwife's). Conclusion These findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources.Item Achieving the millennium development goals for health: Cost effectiveness analysis of strategies for child health in developing countries(2005) Edejer, T.T.; Aikins, M.; Black, R.; Wolfson, L.; Hutubessy, R.; Evans, D.B.Item Beyond fragmentation and towards universal coverage: Insights from Ghana, south africa and the united republic of Tanzania(2008-11) McIntyre, D.; Garshong, B.; Mtei, G.; Meheus, F.; Thiede, M.; Akazili, J.; Ally, M.; Aikins, M.; Mulligan, J.; Goudge, J.The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as " access to adequate health care for all at an affordable price" . A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low- and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage. The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.Item Balancing equity and efficiency in health priorities in Ghana: The use of multicriteria decision analysis(2008-12) Jehu-Appiah, C.; Baltussen, R.; Acquah, C.; Aikins, M.; D'Almeida, S.A.; Bosu, W.K.; Koolman, X.; Lauer, J.; Osei, D.; Adjei, S.OBJECTIVES: To guide the Ministry of Health in Ghana in the priority setting of interventions by quantifying the trade-off between equity, efficiency, and other societal concerns in health. METHODS: The study applied a multicriteria decision analytical framework. A focus group of seven policymakers identified the relevant criteria for priority setting and 63 policymakers participated in a discrete choice experiment to weigh their relative importance. Regression analysis was used to rank order a set of health interventions on the basis of these criteria and associated weights. RESULTS: Policymakers in Ghana consider targeting of vulnerable populations and cost-effectiveness as the most important criteria for priority setting of interventions, followed by severity of disease, number of beneficiaries, and diseases of the poor. This translates into a general preference for interventions in child health, reproductive health, and communicable diseases. CONCLUSION: Study results correspond with the overall vision of the Ministry of Health in Ghana, and are instrumental in the assessment of present and future investments in health. Multicriteria decision analysis contributes to transparency and accountability in policymaking.Item National mass drug administration costs for lymphatic filariasis elimination(2007-10-31) Goldman, A.S.; Guisinger, V.H.; Aikins, M.; Amarillo, M.L.A.; Belizario, V.Y.; Garshong, B.; Gyapong, J.; Kabali, C.; Kamal, H.A.; Kanjilal, S.; Kyelem, D.; Lizardo, J.; Malecela, M.; Mubyazi, G.; Nitiema, P.A.; Ramzy, R.M.; Streit, T.G.; Wallace, A.; Brady, M.A.; Rheingans, R.; Ottesen, E.A.; Haddix, A.C.BACKGROUND: Because lymphatic filariasis (LF) elimination efforts are hampered by a dearth of economic information about the cost of mass drug administration (MDA) programs (using either albendazole with diethylcarbamazine [DEC] or albendazole with ivermectin), a multicenter study was undertaken to determine the costs of MDA programs to interrupt transmission of infection with LF. Such results are particularly important because LF programs have the necessary diagnostic and treatment tools to eliminate the disease as a public health problem globally, and already by 2006, the Global Programme to Eliminate LF had initiated treatment programs covering over 400 million of the 1.3 billion people at risk. METHODOLOGY/PRINCIPAL FINDINGS: To obtain annual costs to carry out the MDA strategy, researchers from seven countries developed and followed a common cost analysis protocol designed to estimate 1) the total annual cost of the LF program, 2) the average cost per person treated, and 3) the relative contributions of the endemic countries and the external partners. Costs per person treated ranged from $0.06 to $2.23. Principal reasons for the variation were 1) the age (newness) of the MDA program, 2) the use of volunteers, and 3) the size of the population treated. Substantial contributions by governments were documented - generally 60%-90% of program operation costs, excluding costs of donated medications. CONCLUSIONS/SIGNIFICANCE: MDA for LF elimination is comparatively inexpensive in relation to most other public health programs. Governments and communities make the predominant financial contributions to actual MDA implementation, not counting the cost of the drugs themselves. The results highlight the impact of the use of volunteers on program costs and provide specific cost data for 7 different countries that can be used as a basis both for modifying current programs and for developing new ones.Item Working practices and incomes of health workers: Evidence from an evaluation of a delivery fee exemption scheme in Ghana(2007-01) Witter, S.; Kusi, A.; Aikins, M.BACKGROUND: This article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana. METHODS: A structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained. RESULTS: Health workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client - $1.09 - is similar to a nurse's (and lower than a private midwife's). CONCLUSION: These findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources.Item Cost effectiveness analysis of strategies for child health in developing countries(2005-11) Edejer, T.T.; Aikins, M.; Black, R.; Wolfson, L.; Hutubessy, R.; Evans, D.B.Abstract OBJECTIVE: To determine the costs and effectiveness of selected child health interventions-namely, case management of pneumonia, oral rehydration therapy, supplementation or fortification of staple foods with vitamin A or zinc, provision of supplementary food with counselling on nutrition, and immunisation against measles. DESIGN: Cost effectiveness analysis. DATA SOURCES: Efficacy data came from published systematic reviews and before and after evaluations of programmes. For resource inputs, quantities came from literature and expert opinion, and prices from the World Health Organization Choosing Interventions that are Cost Effective (WHO-CHOICE) database, RESULTS: Cost effectiveness ratios clustered in three groups, with fortification with zinc or vitamin A as the most cost effective intervention, and provision of supplementary food and counselling on nutrition as the least cost effective. Between these were oral rehydration therapy, case management of pneumonia, vitamin A or zinc supplementation, and measles immunisation. CONCLUSIONS: On the grounds of cost effectiveness, micronutrients and measles immunisation should be provided routinely to all children, in addition to oral rehydration therapy and case management of pneumonia for those who are sick. The challenge of malnutrition is not well addressed by existing interventions.Item Towards a multi-criteria approach for priority setting: An application to ghana(2006-07) Baltussen, R.; Stolk, E.; Chisholm, D.; Aikins, M.BACKGROUND: Many criteria have been proposed to guide priority setting in health, but their relative importance has not yet been determined in a way that allows a rank ordering of interventions. METHODS: In an explorative study, a discrete choice experiment was carried out to determine the relative importance of different criteria in identifying priority interventions in Ghana. Thirty respondents chose between 12 pairs of scenarios that described interventions in terms of medical and non-medical criteria. Subsequently, a composite league table was constructed to rank order a set of interventions by mapping interventions on those criteria and considering the relative weights of different criteria. RESULTS: Interventions that are cost-effective, reduce poverty, target severe diseases, or target the young had a higher probability of being chosen than others. The composite league table showed that high priority interventions in Ghana are prevention of mother to child transmission in HIV/AIDS control, and treatment of pneumonia and diarrhoea in childhood. Low priority interventions are certain interventions to control blood pressure, tobacco and alcohol abuse. The composite league table lead to a different and more differentiated rank ordering of interventions compared to pure efficiency ratings. CONCLUSION: This explorative study has introduced a multi-criteria approach to priority setting. It has shown the feasibility of accounting for efficiency, equity and other societal concerns in prioritization decisions, and its potentially large impact on priority setting.Item What are the Technical and Allocative Efficiencies of Public Health Centres in Ghana(GHANA MEDICAL JOURNAL, 2008) Akazili, J.; Adjuik, M.; Chatio, S.; Kanyomse, E.; Hodgson, A.; Aikins, M.; Gyapong, J.O.Introduction: Health systems in developing countries including Ghana are faced with critical resource constraints in pursuing the goal of improving the health status of the population. The constrained ability to adequately meet health care needs is exacerbated by inefficiency in the health care systems, especially within public health centres. Methods: The study used Data Envelopment Analysis (DEA) method, to calculate the technical and allocative efficiency of 113 randomly sampled health centres. A logistic regression model was also applied on whether a health centre was technically efficient or not to determine the factors that significantly influence the efficiency of health centres. Findings: The findings showed that 78% of health centres were technically inefficient and so were using resources that they did not actually need. Eight-eight percent were also allocatively inefficient. The overall efficiency, (product of the technical and allocative efficiency), was also calculated and over 90% of the health centres were inefficient. The results of a logistic regression analysis show that newer health centres and those which receive incentives were more likely to be technically efficient compared to older health centres and those who did receive incentives. Conclusion: The results broadly point to grave inefficiency in the health care delivery system of the health centres and that lots of resources could be saved if measures were put in place to curb the waste. Incentives to health centres were found to be major motivating factors to the promotion of efficiency.