Tangible Cost-of-Illness as Basis of Cost-Effective Interventions Against Infectious Diseases in Developing Countries, Exemplified by the Nouna Health District
Final Report Abstract
The use of precise, reliable and updated cost information is the central guiding factor for the formulation of evidence-based health policies. This is particularly important in low income countries like Burkina Faso, where the suboptimal allocation of budgets can lead to higher morbidity and mortality. However, there are only very few routine cost information systems that are established to work in the long run. Therefore a comprehensive provider- and household cost-information system was installed in the Nouna health district complementary to to the existing research programme of SFB 544. In collaboration with local partners (Centré de Recherche en Santé de Nouna), parallel to the existing Demographic Sureillance System and linked with the Nouna Health District Household Survey the necessary provider and household data were collected to estimate health costs according to the Cost-of-illness concept. They consist of direct costs of the health care provider, the direct costs of the private households (e. g. transport to and from health care insitutitions for the patient) and the indirect costs of the private household (e. g. loss of labor due to illness). The collected data were used to calculate the total costs-of-illness of households. The estimated direct cost per household per year represented 6% of household proxy income. Richer households had a higher expenditure on health compared to the poor households. Furthermore, the COI of diseases, e.g. Malaria, were analysed. Based on the household cost-information-system it was found out, that even at very low levels of health care utilisation and modest amount of health expenditure, 6–15% of total households in Nouna District incurred catastrophic health expenditure. Overall, household indirect cost was higher than direct cost irrespective of the valuation methods used. Indirect cost assessed by willingness-to-pay method was considerably higher than other methods. Complementary to the calculation of COI for some special diseases from the household’s side, treatment costs can also be determined from the provider’s side, using e.g. a clinical pathway. The average actual provider cost of treating a paediatric Malaria case in Nouna district hospital were 6.74 US$ for a paediatric outpatient with Malaria, 61.08 US$ for a paediatric Malaria inpatient with anaemia and, respectively 74.29 US$ for a case of paediatric Malaria with neurological affections. 54% of the cost was due to laboratory work. This amount is comparable to what was found in similar settings in Senegal and Kenya. Within the context of further analyses it was discovered, that there seems to be a substantial wastage of resources, namely expensive devices and labour time of staff due to underutilisation. Provider data were also used to analyse the cost structure of the health facilities. It was found out that most of them do not operate at an efficient level – due to a severe underutilisation. As most of the costs are fixed an expending access to primary care is possible with a very moderate increase of additional budgets: If the demand for consultancies would rise by 127% and of the delivery services by 48% respectively, this would lead merely to an increase of required resources of 4.2%. As the cost recovery rate in the health facilities is quite low, these further budgets have to be provided additionally, e.g. by the government. For ethical reasons it is not appropriate to try to improve health centres’ efficiency by closing some of them. Their efficiency can be improved and lives can be saved if the access to them is enhanced. Although the Nouna costing project is (nearly) finished, it’s “spirit” will continue. It can be treated as great success, that the INDEPTH network has articulated its interest in introducing the concept that was developed in the Nouna health district, in some sites in Africa and Asia and to provide a framework for innovative meta-analyses. This also reflects the growing awareness into the importance of installing cost information systems in developing countries. Beyond that it also demonstrates the importance of the Nouna project. Within the implementation of the project there have been some problems because of fluctuation of staff in Burkina Faso and consequently some difficulties in getting data. These kinds of problems are not unusual for research in collaboration with people from developing countries.
Publications
- (2004): Provider Cost Information System in Nouna (Burkina Faso). Symposium on malaria and poverty. Nouna, Burkina Faso, December 2004
Mariko, M.; Fleßa, S.
- (2004): The disutility of malaria: can getting sick make you poor? Symposium on malaria and poverty. Nouna, Burkina Faso, December 2004
Pokhrel, S.; Fleßa, S.
- (2005): Efficiency – the basic paradigm of health economics and its application to health financing. KfW analysis Summer School 2005. Kreditanstalt für Wiederaufbau, Frankfurt a.M., Juni 2005
Fleßa, S.
- (2005): Gender role and child health care utilization in Nepal. Health Policy, Vol. 74, S. 100-109
Pokrhel, S.; Fleßa, S.
- (2005): Gender role and child health care utilization in Nepal. Health Policy. Vol. 74, S. 100-109
Pokhrel, S.; Fleßa, S.
- (2005): Household catastrophic health expenditure: implication for equity and access to health care. 2nd international conference on health financing in developing countries. Clermond-Ferrand, Dezember 2005
Su, T.; Kouyaté, B.; Fleßa, S.
- (2005): Locating health facilities in Nouna district, Burkina Faso. Operations Research 2005. Bremen, September 2005
Cocking, C.; Reinelt, G.; Fleßa, S.
- (2005): Mögliche Auswirkungen des Klimawandels auf die Ausbreitung der Malaria Tropica – Ergebnisse einer strategischen Simulation. Das Gesundheitswesen, Vol. 67, S. 492-497
Fleßa, S.; Müller, O.
- (2005): The use of discrete-event simulation to evaluate strategies for the prevention of mother-to-child transmission of HIV in developing countries. Journal of the Operational Research Society 56, 222 – 233
Rauner, M.S.; Brailsford, S.C.; Fleßa, S.
- Modelling the effectiveness of financing policies to address underutilization of children’s health services in Nepal. Bulletin of the World Health Organization, Vol. 83, No. 5, S. 339-346
Pokhrel, S.; Hidayat, B.; Fleßa, S.; Sauerborn, R.
- (2006): Catastrophic household expenditure for health care in a low-income society: a study from Nouna District, Burkina Faso. Bulletin of the World Health Organisation, Vol. 84(1), S. 21-27
Su, T.; Kouyaté, B.; Fleßa, S.
- (2006): Determinants of household health expenditure on western institutional health care. European Journal of Health Economics, Vol. 7, No. 3, S. 199-207
Su, T.T.; Pokhrel, S.; Gbangou, A.; Fleßa, S.
- (2006): Evaluierung von Gesundheitsprojekten in Entwicklungsländern – Beispiele für die Wahl der Ergebniskriterien. Gesundheitsökonomie & Qualitätsmanagement, Vol. 1, S. 87-96
Fleßa, S.
- (2006): How much time do health services spend on antenatal care? Implications for the introduction of the focused antenatal care model in Tanzania. British Medical Journal Pregnancy and Childbirth, Vol. 23, No.6, S. 226- 228
Both, C. von; Fleßa, S.; Makuwani, A.; Mpenbeni, R.; Jahn, Methodology A.
- (2006): Implementing a comprehensive cost information system in rural health facilities - The case of Nouna Health District, Burkina Faso. Tropical Medicine and International Health, Vol. 11, No. 9, S. 1452-1465
Fleßa, S.; Kouyatè, B.
- (2006): Investing in Health: Overcoming the Poverty Trap by Effective and Efficient Health Care. European Health Conference – Challenges of Delivering Health in the Enlarged Europe – Experience and Perspectives from Member States and Accession Countries. Sofia (Bulgarien), September 2006
Fleßa, S.
- (2006): Locating health facilities in Nouna District, Burkina Faso. Haasis, H.-D.; Kopfer, H.; Schönberger, J. (Hrsg.): Operations Research Proceedings 2005. Springer, Berlin et al., S. 431-436
Cocking, C.; Fleßa, S.; Reinelt, G.
- (2007): Assessment of indirect cost-of-illness in subsistance farming society by using different valuation methods. Health Policy, Vol. 83, S. 353-362
Su, T.T.; Sanon, M.; Flessa, S.
- (2008): Basic health care package without antiretroviral therapy? Journal of Public Health, Vol. 16, S. 145-150
Flessa, S.
- (2008): Expanding access to primary care without additional budgets? A case study from Burkina Faso. European Journal of Health Economics, Vol. 9, S. 393-403
Marschall, P.; Fleßa, S.
- (2008): Primary Health Care und Effizienz von Gesundheitsversorgung. Fachtagung Primary Health Care in 21. Jahrhundert – Blicke auf eine zukunftsfähige Gesundheitsversorgung 30 Jahre nach Alma Ata. Berlin, November 2008
Fleßa, S.
- (2008): The Nouna COI information system: Approach, lessons learned, and implications for INDEPTH. Cost-of-illness Workshop, Moundasso/ Nouna, Burkina Faxo, Juni 2008
Marschall, P.
- (2009). Socio-economic Impact of Antiviral Intervention : Kräusslich, H.G., Bartenschlager R. (Eds.). Handbook of Experimental Pharmacology Antiviral Therapy 189, Springer-Verlag, Heidelberg u. a., S. 347-374
Fleßa, S.; Marschall, P.
- (2009): Assessing the Performance of Health Centres in Rural Burkina Faso Using DEA. Journal of Public Health, Vol. 17, No.2, S. 87-95
Marschall, P.; Fleßa, S.
- (2009): Costing of health care services in developing countries. Lang, Frankfurt et al.
Fleßa, S.
