Economic burden of caregiving for persons with severe mental illness in sub-Saharan Africa: A systematic review

© 2018 Addo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Over the past two decades, the focus of mental health care has shifted from institutionalisation to community-based programs and short hospital stays. This change means that there is an increased role for caregivers, mostly family members, in managing persons with mental illness. Although there is evidence to support the benefits of deinstitutionalisation of mental health care, there are also indications of substantial burden experienced by caregivers; the evidence of which is limited in sub-Saharan Africa. However, knowledge of the nature and extent of this burden can inform the planning of mental health services that will not only benefit patients, but also caregivers and households. Objective To systematically review the available evidence on the economic burden of severe mental illness on primary family caregivers in sub-Saharan Africa. Methods A comprehensive search was conducted in Pubmed, CINAHL, Econlit and Web of Science with no date limitations up to September 2016 using keywords such as "burden", "cost of illness" and "economic burden" to identify relevant published literature. Articles were appraised using a standardised data extraction tool covering themes such as physical, psychological and socioeconomic burden. Results Seven papers were included in the review. Caregivers were mostly family members with a mean age of 46.34, female and unemployed. Five out of seven studies (71%) estimated the full economic burden of severe mental illness on caregivers. The remainder of studies just described the caregiver burden. All seven papers reported moderate to severe caregiver burden characterised by financial constraint, productivity loss and lost employment. The caregiver’s level of income and employment status, severity of patient’s condition and duration of mental illness were reported to negatively affect the economic burden experienced by caregivers. Conclusion There is paucity of studies reporting the burden of severe mental illness on caregivers in sub-Saharan Africa. Further research is needed to present the nature and extent of this burden to inform service planning and policymaking

Benefit-cost analysis of electronic claims processing under Ghana's National Health Insurance Scheme.

OBJECTIVE: The aim of this study was to evaluate the benefit-cost of E-claims. A benefit-cost analysis was used to evaluate the efficiency of E-claims from the perspective of the providers and the purchaser. DESIGN: A benefit-cost analysis approach was taken for this economic evaluation. Furthermore, we estimated the incremental benefit-cost ratio (IBCR) of the intervention under assessment. PARTICIPANTS: Purchasers and healthcare providers of the National Health Insurance Scheme (NHIS) of Ghana were the study population. RESULTS: The analysis was stratified according to providers and purchaser. Cost incurred in processing claims electronically and manually were estimated by assessing the resource use and their corresponding costs. Sensitivity analysis was conducted to assess the robustness of the results to variations in discount rate and proportions of claims processed under E-claims compared with paper claims. The combined sample of providers and purchaser made incremental gains from processing claims electronically. The IBCR was -19.75, 25.56 and 5.10 for all (sample) providers, purchaser and both providers and purchaser, respectively. When projected for the 330 facilities submitting claims to the NHIS claims processing centre (CPC) as at December 2014, the IBCR were -35.20, 25.56 and 90.06 for all providers, purchaser and both providers and purchaser. The results were sensitive to the discount rate used and proportions of E-claims compared with paper claims. CONCLUSION: Electronic processing of claims is more efficient compared with manual processing, hence provide an economic case for scaling it up to cover many more healthcare facilities and NHIS CPCs in the Ghana

Integrating Qualitative Techniques in Model Development: A Case Study Using the Framework Approach

Background Despite their potential, there is limited uptake of formal qualitative methods in model development by modellers and health economists. The aim of this case study was to highlight in a real-world context how a qualitative approach has been applied to gain insight into current practice (delineating existing care pathways) for typhoid fever in Ghana, which can then assist in model structure conceptualisation in a model-based cost-effectiveness analysis. Methods The perspectives of a range of healthcare professionals working in different settings and across different practices in the Eastern region of Ghana were captured with a self-administered survey using open-ended questions and analysed using the framework method. Results A total of 51 completed questionnaires were retrieved representing a 73% response rate. It was found that two main care pathways for typhoid fever exist in Ghana and there was no consensus on how a new test might be applied to the existing pathways. Conclusion The two settings in Ghana have different care pathways and any cost-effectiveness analysis should consider the alternative pathways separately. This study demonstrated that framework analysis is a qualitative methodology that is likely to be accessible and feasible across a wide range of health economic settings

An EQ-5D-5L Value Set for Ghana Using an Adapted EuroQol Valuation Technology Protocol.

OBJECTIVES: Ghana's economic evaluation reference case recommends quality-adjusted life-years as an outcome measure for the conduct of cost-utility analysis. There is no Ghanaian value set available to be used in estimating quality-adjusted life-years. This study aimed to develop a value set for Ghana using the EQ-5D-5L instrument. METHODS: Face-to-face preference data were collected from 300 adults across 3 regions of Ghana using the adapted version of the EuroQol valuation technology (EQ-VT) standardized valuation protocol; with composite time-trade-off (cTTO) and discrete-choice experiments (DCEs) elicitation techniques. The cTTO and DCE data were modeled individually or together to provide complementary results on respondents' utility preferences. Models explored were generalized least squares, Tobit, heteroskedastic, logit, and hybrid. The best-fitting model for the value set was selected based on its logical consistency, accounting for left-censored and heteroscedasticity data, and the statistical significance of parameters. RESULTS: The 300 interviews provided 4500 cTTO responses and 4200 DCE responses. The preferred model chosen for the Ghana value set was the Hybrid Tobit random effect heteroscedastic-constrained model. The predicted value for the worst attainable health state (55555) was -0.493 and the best health state (11112) was 0.969. The largest decrement was registered for level 5 mobility (0.369) followed by pain/discomfort (0.312), self-care (0.273), anxiety/depression (0.271), and usual activities (0.268). CONCLUSIONS: This is the first Ghanaian EQ-5D-5L value set based on social preference derived from a nationally representative sample. The value set will play a key role in the use of economic evaluation studies to inform priority setting in Ghana where different health technologies can be compared

Economic burden of motorcycle accidents in Northern Ghana

Background: Motorcycles are the most popular means of transportation in northern Ghana, and their accidents are major causes of out-patient attendance and admis-sions in the Bolgatanga Municipality.Objective: This paper estimates the economic burden of motorcycle accidents in the Bolgatanga Municipality in Northern Ghana.Design: Retrospective cross-sectional cost study.Methods: Data were collected from Drivers and Vehi-cle Licensing Authority, the Police, health facilities and motorcycle accident victims. Both  quantitative and qualitative approaches were used for data collection. Cost analysis was based on the standard road accident cost conceptual framework.Results: Ninety-eight percent of vehicles registered in the municipality in 2004 – 2008 were motorcycles. The motorcycles were significantly more than the cars reg-istered. The economic burden of motorcycle accidents was estimated to be about US$1.2 million, of which, 52% were accident-related costs (i.e. property damage and administration) and 48% casualty-related costs (i.e. medical costs, out-of-pocket expenses, lost labour out-puts, intangible costs and funeral expenses). Most mo-torcycle accident victims were in their productive ages and were males. Only a third of the motorcycles were insured. Majority of the riders (71%) did not possess valid driving license and would want to avoid the po-lice. Main motorcycle injuries were head injuries, frac-tures, lacerations and contusions. Majority of the acci-dents were caused by lack of formal motorcycle riding training, abuse of alcohol, unrestrained animals and donkey carts.Conclusion: Motorcycle accidents could be reduced through law enforcement, continuous mass education and helmet use

Sociodemographic determinants of health insurance enrolment and dropout in urban district of Ghana: A cross-sectional study

Background: Earlier studies have found significant associations between sociodemographic factors and enrolment in the National Health Insurance Scheme (NHIS) in Ghana. These studies were mainly household surveys in relatively rural areas with high incidence of poverty. To expand the scope of existing evidence, this paper examines policy design factors associated with enrolment and dropout of the scheme in an urban poor district using routine secondary data. Methods: This study is a cross-sectional quantitative analysis of 2014-2016 NHIS enrolment data of the Ashiedu Keteke district office. Descriptive and multivariate logistic regression analyses were performed to examine sociodemographic factors associated with NHIS enrolment and dropout. Results: A total of 215,724 individuals enrolled in the NHIS over the period under study, of which 98,232 (46%) were new members. About 41% of existing members in 2014 dropped out of the NHIS in 2015 and 53% of those in 2015 dropped out in 2016. The indigents (core poor) are significantly more likely to enrol and to drop out of the NHIS. However, the males, informal sector employees, social security and national insurance trust (SSNIT) contributors, and the aged (70+ years) are significantly less likely to enrol in the NHIS but more likely to retain coverage. Conclusions: A considerable number of members are dropping out of the NHIS. The indigents in particular, are increasingly enrolling in and dropping out of the NHIS whilst the males, informal sector employees, SSNIT contributors and the aged are not enrolling as expected but increasingly retaining coverage. Policy reforms to ensuring continued growth towards realization of universal health coverage should take these factors into consideration

Financing immunisation in Kenya: examining bottlenecks in health sector planning and budgeting at the decentralised level

BACKGROUND: Decentralisation has increasingly been adopted by countries as an important health sector reform aimed at increasing community participation in decision making while enhancing swift response at decentralised levels, to accelerate the attainment of health system goals. Kenya adopted a devolved system of government where health services delivery became a function of the 47 semi-autonomous county governments with planning and budgeting functions practised at both levels of government. This study sought to explore challenges facing health sector planning and budgeting and how they affect immunisation service delivery at the county level. METHODS: Data were collected through 77 in-depth interviews of senior county department of health officials across 15 counties in Kenya. We applied an inductive thematic approach in analysing the qualitative data using NVIVO software. FINDINGS: The study found a lack of alignment between planning and budgeting processes, with planning being more inclusive compared to budgeting. Inadequate capacity in conducting planning and budgeting and political interference were reported to hinder the processes. Limited budget allocations and delayed and untimely disbursement of funds were reported to affect execution of health and immunisation budgets. Low prioritisation of preventive health interventions like immunisation due to their perceived intangibility influenced resource allocation to the programs. CONCLUSION: The findings highlight the need for effective strategies to align planning and budgeting processes, increased technical support to counties to enhance the requisite capacity, and efforts to improve budget execution to improve budget credibility. Counties should plan to increase their funding commitment toward immunisation to ensure sustainability of the program as Kenya transitions from GAVI support

IDF21-0168 pathway to clinical diabetes services in COVID-19 era : what has changed and what are the implications?

BACKGROUND: The known barriers to delivering clinical NCD services in lower-middle-income countries (LMICs) have been exacerbated with the onset of COVID-19. Health facility-instituted COVID-19 control measures could compromise the pathway for seeking care and impact chronic disease care that needs to be examined for future policy direction. AIM: This paper examines the changes COVID-19 has brought to diabetes service delivery in LMICs, using Ghana as a case study, and raises questions on the implication of such changes on the individual- and population-level diabetes treatment outcomes by exploring service provider perspectives. Ghana first recorded COVID-19 cases in March 2020, and from April, the government started implementing lockdown measures as well as closing hospitals’ outpatient services, including diabetes clinics and other NCDs services. METHOD: We conducted eighteen semi-structured personal interviews with healthcare providers in primary, secondary and tertiary facilities within the Ghana Health Service. The topic guide was developed from a literature review conducted for this study and addressed issues such as COVID-19 and service organisation, staffing, referrals, patient concerns, data management and insurance. The interviews were conducted between November 2020 and February 2021, when outpatient services, including diabetes clinics, resumed operations. The analysis was performed using inductive and deductive methods in NVivo 1.4.1. RESULTS AND DISCUSSION: The study found that suboptimal patient appointments and reminder systems result in overcrowded diabetes clinics, further increasing the risk of COVID19 epidemic in hospitals. Tackling overcrowded diabetes clinics is urgently needed with the potential for patients and providers becoming infected with COVID-19. Engineering controls, e.g. fans instead of air conditioners to improve air circulation and ventilation, can help minimize transmission in hospital buildings. COVID-19 controls, e.g., extended time intervals between reviews, fewer appointments per clinic day, and shorter consultation durations, limit opportunities for clinicians to intervene in patients’ conditions and consequently lead to poor treatment outcomes. Health systems need to investigate the cost effectiveness of such controls to support policy decisions. National health insurance and drug policies limit health facilities and diabetes patients access to medicines in the COVID-19 era. Restrictions on the procurement and sales of insured medicines to patients contributed to the shortage of diabetes medication. Granted permission to procure medicines on the open market, a limit on the profit margin to put on medicine cost can result in a loss for health facilities. Known diabetes service delivery challenges, e.g. few trained providers, high treatment cost, and drug shortage, were aggravated, particularly in ambulatory care, during the pandemic. The UK and Italy adapted Facebook chatting, video tele-consultation and government websites for delivering diabetes care during the COVID-19 pandemic. However, we are aware that resource constraints may limit the implementation of similar strategies in LMICs. Our study suggests that COVID-19 presents additional challenges and worsens existing barriers to diabetes service delivery for clinicians and people living with diabetes. These challenges could have negative implications for population-level diabetes treatment outcome, interfering with the sustainable development goals. Further research remains to assess the effect of COVID-19-related structural changes on treatment adherence and outcomes in practice

The Costs of Implementing Vaccination With the RTS,S Malaria Vaccine in Five Sub-Saharan African Countries.

Background. The World Health Organization has recommended pilot implementation of a candidate vaccine against malaria (RTS,S/AS01) in selected sub-Saharan African countries. This exploratory study aimed to estimate the costs of implementing RTS,S in Burkina Faso, Ghana, Kenya, Mozambique, and Tanzania. Methods. Key informants of the expanded program on immunization at all levels in each country were interviewed on the resources required for implementing RTS,S for routine vaccination. Unit prices were derived from the same sources or from international price lists. Incremental costs in 2015 US dollars were aggregated per fully vaccinated child (FVC). It was assumed the four vaccine doses were either all delivered at health facilities or the fourth dose was delivered in an outreach setting. Results. The costs per FVC ranged from US$25 (Burkina Faso) to US$37 (Kenya) assuming a vaccine price of US$5 per dose. Across countries, recurrent costs represented the largest share dominated by vaccines (including wastage) and supply costs. Non-recurrent costs varied substantially across countries, mainly because of differences in needs for hiring personnel, in wages, in cold-room space, and equipment. Recent vaccine introductions in the countries may have had an impact on resource availability for a new vaccine implementation. Delivering the fourth dose in outreach settings raised the costs, mostly fuel, per FVC by less than US$1 regardless of the country. Conclusions. This study provides relevant information for donors and decision makers about the cost of implementing RTS,S. Variations within and across countries are important and the unknown future price per dose and wastage rate for this candidate vaccine adds substantially to the uncertainty about the actual costs of implementation

Treatment choices for fevers in children under-five years in a rural Ghanaian district

<p>Abstract</p> <p>Background</p> <p>Health care demand studies help to examine the behaviour of individuals and households during illnesses. Few of existing health care demand studies examine the choice of treatment services for childhood illnesses. Besides, in their analyses, many of the existing studies compare alternative treatment options to a single option, usually self-medication. This study aims at examining the factors that influence the choices that caregivers of children under-five years make regarding treatment of fevers due to malaria and pneumonia in a rural setting. The study also examines how the choice of alternative treatment options compare with each other.</p> <p>Methods</p> <p>The study uses data from a 2006 household socio-economic survey and health and demographic surveillance covering caregivers of 529 children under-five years of age in the Dangme West District and applies a multinomial probit technique to model the choice of treatment services for fevers in under-fives in rural Ghana. Four health care options are considered: self-medication, over-the-counter providers, public providers and private providers.</p> <p>Results</p> <p>The findings indicate that longer travel, waiting and treatment times encourage people to use self-medication and over-the-counter providers compared to public and private providers. Caregivers with health insurance coverage also use care from public providers compared to over-the-counter or private providers. Caregivers with higher incomes use public and private providers over self-medication while higher treatment charges and longer times at public facilities encourage caregivers to resort to private providers. Besides, caregivers of female under-fives use self-care while caregivers of male under-fives use public providers instead of self-care, implying gender disparity in the choice of treatment.</p> <p>Conclusions</p> <p>The results of this study imply that efforts at curbing under-five mortality due to malaria and pneumonia need to take into account care-seeking behaviour of caregivers of under-fives as well as implementation of strategies.</p