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Joses Muthuri Kirigia,1 Patrick Kinyua Kubai2 1African Sustainable Development Research Consortium (ASDRC), Nairobi, Kenya; 2Meru University of Science and Technology (MUST), Meru, KenyaCorrespondence: Joses Muthuri Kirigia, ASDRC, P.O. Box 6994 00100 GPO, Nairobi, Kenya, Email muthurijoses68@gmail.comIntroduction: In 2019, the East African Community (EAC) lost 12,048,918 disability-adjusted life-years (DALY) across all ages from neglected tropical diseases (NTDs). The specific objectives of the study reported in the paper were to estimate for EAC the monetary value of DALYs sustained by all ages from NTDs, and the potential productivity losses within the working age bracket of 15 years and above.Methods: The EAC total monetary value of DALYs lost from all 20 NTDs is the sum of each partner state’s monetary value of DALYs lost from all 20 NTDs. The ith partner state’s monetary value of DALY from jth disease equals ith state’s GDP per capita net of current health expenditure multiplied by DALYs lost from jth disease in 2019. The EAC total productivity losses attributable to DALYs lost from all 20 NTDs is the sum of lost productivity across the seven partner states. The ith partner state’s productivity loss associated with jth disease equals ith state’s GDP per capita net of current health expenditure multiplied by DALYs lost from jth disease and the ith state’s labour force participation rate adjusted for underutilization (unemployment and time-related underemployment) in 2019.Results: The total 12,048,918 DALYs lost in EAC from NTDs had a of International Dollars (Int$) 21,824,211,076 and an average of Int$ 1811 per DALY. The 2,614,464 DALYs lost from NTD among 15-year-olds and above caused an estimated of Int$ 2,588,601,097 (0.392% of the EAC gross domestic product in 2019), and an average of Int$ 990.1 per DALY.Conclusion: The study succeeded in estimating the monetary value of DALYs sustained by all ages from 20 NTDs, and the potential productivity losses within the working age bracket of 15 years and above in the seven EAC partner states. The DALYs lost from NTD among 15-year-olds and above caused a sizeable loss in the economic productivity of EAC.Keywords: neglected tropical diseases, disability-adjusted life years, gross domestic product, current health expenditure, non-health GDP per capita

More than 20% of total health expenditure in 48% of the 46 countries in the WHO African Region is provided by external sources. Issues surrounding aid effectiveness suggest that these countries ought to implement strategies for weaning off aid dependency. This paper broaches the following question: what are some of the strategies that countries of the region can employ to wean off donor funding for health? Five strategies are discussed: reduction in economic inefficiencies; reprioritizing public expenditures; raising additional tax revenues; increased private sector involvement in health development; and fighting corruption. Copyright © 2008 World Health Organization [ABSTRACT FROM AUTHOR]

Background: The goal of universal health coverage (UHC) is that every individual has access to high-quality health services without running the consequences of financial hardship. The World health report 2013 "Research for universal health coverage" states a performant National Health Research Systems (NHRS) can contribute by providing solutions to challenges encountered in advancing towards UHC by 2030. Pang et al. define a NHRS as the people, institutions, and activities whose primary aim is to generate and promote utilization of high-quality knowledge that can be used to promote, restore, and/or maintain the health status of populations. The WHO Regional Committee for Africa (RC) adopted a resolution in 2015 urging member states to strengthen their NHRS to facilitate production and utilization of evidence in policy development, planning, product development, innovation, and decision-making. This study aimed to calculate NHRS barometer scores for Mauritius in 2020, identify the gaps in NHRS performance, and recommend interventions for boosting the Mauritius NHRS in the pursuit of UHC., Methods: The study used a cross-sectional survey design. A semi-structured NHRS questionnaire was administered and complemented with a review of documents archived in pertinent Mauritius Government Ministries, universities, research-oriented departments, and non-governmental organizations websites. The African NHRS barometer developed in 2016 for countries to monitor the RC resolution implementation was applied. The barometer consists of four NHRS functions (leadership and governance, developing and sustaining resources, producing and utilizing research, financing research for health [R4H]), and 17 sub-functions, e.g., existence of a national policy on research for health (R4H), presence of a Mauritius Research and Innovation Council (MRIC), existence of knowledge translation platform., Results: In 2020, Mauritius had an overall average NHRS barometer score of 60.84%. The four NHRS functions average indices were 50.0% for leadership and governance, 77.0% for developing and sustaining resources, 52.0% for producing and utilizing R4H, and 58.2% for financing R4H., Conclusion: The performance of NHRS could be improved through the development of a national R4H policy, strategic plan, prioritized agenda, and national multi-stakeholder health research management forum. Furthermore, increased funding for the NHRS may nurture the human resources for health research capacities, hence the number of pertinent publications and health innovations., (© 2023. The Author(s).)

The aim of the United Nations' Sustainable Development Goal (SDG)3 is to ensure healthy lives and promote well-being for all, at all ages; including reducing maternal and child mortality, combating communicable and non-communicable diseases, and achieving Universal Health Coverage (UHC). UHC aims to provide everyone with equal access to quality essential and comprehensive healthcare services including preventions, interventions, and treatments, without exposing them to financial hardship. Making progress toward UHC requires significant investment in technical and financial resources and countries are pursuing the implementation of cost-saving measures within health systems to help them achieve UHC. Whilst many countries are far from attaining UHC, all countries, particularly low- and middle-income countries, can take steps toward achieving UHC. This paper discusses key data showing how immunization is a fundamental, cost-effective tool for reducing morbidity and mortality associated with infectious disease in all populations, creating more productive communities, reducing treatment costs, and consequently, facilitating social and economic advancement. Immunization is key to advancing toward UHC by relieving the burden that diseases place on the healthcare services, freeing essential resources to use elsewhere within the healthcare system. Immunization is an essential, readily available strategy that countries can deploy to achieve UHC and the SDG3 agenda.

In an era of considerable uncertainty about future prospects for development assistance to fund major health programmes in Sub-Saharan Africa, social health insurance is increasingly being considered as an alternative mechanism for increasing financing health. However, empirical support for social health insurance in sub-Saharan Africa remains sparse. The main aim of this study was to examine the viability of increasing health financing through social health insurance in Zambia. The paper uses a large nationally representative household survey to estimate the expected mean and total willingness to pay for social health insurance. The revenue potential of social health insurance for health sector funding is assessed. The results show that despite a high level of public support for social health insurance, with 80% willing to join a social insurance scheme, the estimated mean monthly willingness-to-pay is relatively low at Zambian Kwacha 55 (US$8.8 in 2014 dollars) per household. The evidence presented in this paper suggests that the revenue potential of social health insurance would not be sufficient to fund major improvements in quality of care for insured members, let alone cross-subsidize benefits to non-members., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Mauritius along with other 12 countries in the African Region was identified at the early start of the COVID-19 pandemic as being at high risk due to high volume of international travel, high prevalence of non-communicable diseases and co-morbidities, high population density and significant share of population over 60 years (16%). The objective of this study was to estimate the total discounted money value of human life losses ( TDMVCL MAURITIUS ) associated with COVID-19 in Mauritius. Methods: The human capital approach (HCA) was used to estimate the TDMVCL MAURITIUS of the 10 human life losses linked with COVID-19 in Mauritius as of 16 October 2020. The HCA model was estimated with the national life expectancy of 75.51 years and a discount rate of 3%. A sensitivity analysis was performed assuming (a) 5 and 10% discount rates, and (b) the average world life expectancy of 73.2 years, and the world highest life expectancy of 88.17 years. Results: The money value of human lives lost to COVID-19, at a discounted rate of 3%, had an estimated TDMVCL MAURITIUS of Int$ 3,120,689, and an average of Int$ 312,069 per human life lost. Approximately 74% of the TDMVCL MAURITIUS accrued to persons aged between 20 and 59 years. Reanalysis of the model with 5 and 10% discount rates, holding national life expectancy constant, reduced the TDMVCL MAURITIUS by 19.0 and 45.5%, respectively. Application of the average world life expectancy at 3% discount rate reduced TDMVCL MAURITIUS by 13%; and use of the world highest life expectancy at 3% discount rate increased TDMVCL MAURITIUS by 50%. Conclusions: The average discounted money value per human life loss associated with COVID-19 is 12-fold the per capita GDP for Mauritius. All measures implemented to prevent widespread community transmission of COVID-19 may have saved the country 837 human lives worth Int$258,080,991. This evidence, conjointly with human rights arguments, calls for increased investments to bridge the existing gaps for achieving universal health coverage by 2030., (Copyright © 2020 Musango, Nundoochan and Kirigia.)

Background: This study estimates the total discounted value of human lives lost (TDVHL) due to COVID-19 in France as of 14 September 2020. Methods: The human capital approach (HCA) model was used to estimate the TDVHL of the 30,916 human lives lost due to COVID-19 in France; i.e., assuming a discount rate of 3% and the national average life expectancy at birth of 83.13 years. To test the robustness of the estimated TDVHL, the model was rerun (a) using 5% and 10% discount rates, while holding the French average life expectancy constant; and (b) consecutively substituting national life expectancy with the world average life expectancy of 73.2 years and the world highest life expectancy of 88.17 years.  Results: The human lives lost had a TDVHL of Int$10,492,290,194, and an average value of Int$339,381 per human life lost. Rerun of the HCA model with 5% and 10% discount rates decreased TDVHL by Int$1,304,764,602 (12.4%) and Int$3,506,938,312 (33%), respectively. Re-calculation of the model with the world average life expectancy decreased the TDVHL by Int$7,750,187,267 (73.87%). Contrastingly, re-estimation of the model with the world's highest life expectancy augmented TDVHL by Int$3,744,263,463 (35.7%). Conclusions: The average discounted economic value per human life lost due to COVID-19 of Int$339,381 is 8-fold the France gross domestic product per person. Such evidence constitutes an additional argument for health policy makers when making a case for increased investment to optimise France's International Health Regulation capacities and coverage of essential health services, and safely managed water and sanitation services., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 Kirigia JM et al.)

Background: Suicide is an important public health problem in the African continent whose economic burden remains largely unknown. This study estimated the monetary value of human lives lost due to suicide in the African continent in 2017. Methods: The human capital approach was applied to monetarily value the years of life lost due to premature mortality from suicide deaths (SD) among 54 African countries. A 3% discount rate was used to convert future losses into their present values. The sensitivity of monetary value of human lives lost to changes in discount rate and average life expectancy was tested. Results: The 75,505 human lives lost from suicide had a grand total monetary value of International Dollars (Int$) 6,989,963,325; and an average present value of Int$ 92,576 per SD. About 31.1% of the total monetary value of SD was borne by high-income and upper-middle-income countries (Group 1); 54.4% by lower-middle-income countries (Group 2); and 14.5% by low-income countries (Group 3). The average monetary value per human life lost from SD was Int$ 234,244 for Group 1, Int$ 109,545 for Group 2 and Int$ 32,223 for Group 3. Conclusions: Evidence shows that suicide imposes a substantive economic burden on African economies. The evidence reinforces the case for increased investments to ensure universal coverage of promotive, preventive, curative and rehabilitative mental health services., Competing Interests: The authors declare no conflict of interest.

Objective: According to the WHO coronavirus disease (COVID-19) situation report 35, as of 24th February 2020, there was a total of 77,262 confirmed COVID-19 cases in China. That included 2595 deaths. The specific objective of this study was to estimate the fiscal value of human lives lost due to COVID-19 in China as of 24th February 2020., Results: The deaths from COVID-19 had a discounted (at 3%) total fiscal value of Int$ 924,346,795 in China. Out of which, 63.2% was borne by people aged 25-49 years, 27.8% by people aged 50-64 years, and 9.0% by people aged 65 years and above. The average fiscal value per death was Int$ 356,203. Re-estimation of the economic model alternately with 5% and 10 discount rates led to a reduction in the expected total fiscal value by 21.3% and 50.4%, respectively. Furthermore, the re-estimation of the economic model using the world's highest average life expectancy of 87.1 years (which is that of Japanese females), instead of the national life expectancy of 76.4 years, increased the total fiscal value by Int$ 229,456,430 (24.8%).

Background: The objectives of the study reported in this paper were: (a) to score the coverage of core NCD population-based interventions and individual services in Mauritius; (b) to analyse and score the presence of 15 common health system challenges that impede delivery of core NCD interventions and services in Mauritius; and (c) to provide policy recommendations for Mauritius to address health system barriers to delivery of NCD interventions and services., Methods: The Mauritius country assessment applied the guidelines developed by the World Health Organization Regional Office for Europe for systematically scoring coverage of NCD interventions and assessing health system challenges for improving NCD outcomes. The assessment used qualitative research design approach., Results: Of the 24 core population-based interventions for addressing key NCD risk factors, 16.7% were rated extensive, 37.5% moderate and 45.8% limited. Three (20%), 8 (53%) and 4 (27%) of the 15 individual/personal CVD, diabetes and cancer services were rated extensive, moderate and limited respectively. The top five health system challenges hampering scale-up of coverage of population-based NCD interventions in Mauritius were inadequate interagency cooperation; limited application of explicit priority setting approaches; inadequate change management; sub-optimal distribution and mix human resources; insufficient population empowerment; and insufficient political commitment. The top five challenges had average scores of between 3.1 (interagency cooperation) and 2.4 (distribution and mix of human resources). The top five health system challenges constraining expansion in coverage of individual NCD services were limited integration of evidence into practice; limited use of explicit priority-setting approaches; inadequate application of information and technology solutions; insufficient population empowerment; and sub-optimal distribution and mix of human resources. The top five challenges for individual interventions had mean scores varying between 2.6 (integration of evidence into practice) and 1.7 (distribution and mix of human resources)., Conclusions: Mauritius needs to increase its domestic general government investments into the national health system and requisite multi-sectoral action to address the priority health system challenges with a view of bridging the existing gaps in coverage of NCD population-based interventions and individual services.

Background: Between 8 May 2018 and 27 May 2019, cumulatively there were 1286 deaths from Ebola Virus Disease (EVD) in the Democratic Republic of Congo (DRC). The objective of this study was to estimate the monetary value of human lives lost through EVD in DRC., Methods: Human capital approach was applied to monetarily value years of life lost due to premature deaths from EVD. The future losses were discounted to their present values at 3% discount rate. The model was reanalysed using 5 and 10% discount rates. The analysis was done alternately using the average life expectancies for DRC, the world, and the Japanese females to assess the effect on the monetary value of years of life lost (MVYLL)., Results: The 1286 deaths resulted in a total MVYLL of Int$17,761,539 assuming 3% discount rate and DRC life expectancy of 60.5 years. The average monetary value per EVD death was of Int$13,801. About 44.7 and 48.6% of the total MVYLL was borne by children aged below 9 years and adults aged between 15 years and 59 years, respectively. Re-estimation of the algorithm with average life expectancies of the world (both sexes) and Japanese females, holding discount rate constant at 3%, increased the MVYLL by Int$ 3,667,085 (20.6%) and Int$ 7,508,498 (42.3%), respectively. The application of discount rates of 5 and 10%, holding life expectancy constant at 60.5 years, reduced the MVYLL by Int$ 4,252,785 (- 23.9%) and Int$ 9,658,195 (- 54.4%) respectively., Conclusion: The EVD outbreak in DRC led to a considerable MVYLL. There is an urgent need for DRC government and development partners to disburse adequate resources to strengthen the national health system and other systems that address social determinants of health to end recurrence of EVD outbreaks.

Background: Health challenges and health systems set-ups differ, warranting contextualised healthcare interventions to move towards universal health coverage. As such, there is emphasis on generation of contextualized evidence to solve local challenges. However, weak research capacity and inadequate resources remain an impendiment to quality research in the African region. WHO African Region (WHO AFR) facilitated the adoption of a regional strategy for strengthening national health research systems (NHRS) in 2015. We assessed the progress in strengthening NHRS among the 47 member states of the WHO AFR., Methods: We employed a cross sectional survey design using a semi structured questionnaire. All the 47member states of WHO AFR were surveyed. We assessed performance against indicators of the regional research strategy, explored facilitating factors and barriers to strengthening NHRS. Using the research barometer, which is a metric developed for the WHO AFR we assessed the strength of NHRS of member states. Data were analysed in Excel Software to calculate barometer scores for NHRS function and sub-function. Thematic content was employed in analysing the qualitative data. Data for 2014 were compared to 2018 to assess progress., Results: WHO AFR member states have made significant progress in strengthening their NHRS. Some of the indicators have either attained or exceeded the 2025 targets. The average regional barometer score improved from 43% in 2014 to 61% in 2018. Significant improvements were registered in the governance of research for health (R4H); developing and sustaining research resources and producing and using research. Financing R4H improved only modestly. Among the constraints are the lengthy ethical clearance processes, weak research coordination mechanisms, weak enforcement of research laws and regulation, inadequate research infrastructure, limited resource mobilisation skills and donor dependence., Conclusion: There has been significant improvement in the NHRS of member states of the WHO AFRO since the last assessment in 2014. Improvement across the different objectives of the regional research strategy is however varied which compromises overall performance. The survey highlighted the areas with slow improvement that require a concerted effort. Furthermore, the study provides an opportunity for countries to share best practice in areas of excellence.

Background: Neglected tropical diseases (NTDs) are an important cause of death and disability in Africa. This study estimates the monetary value of human lives lost due to NTDs in the continent in 2015., Methods: The lost output or human capital approach was used to evaluate the years of life lost due to premature deaths from NTDs among 10 high/upper-middle-income (Group 1), 17 middle-income (Group 2) and 27 low-income (Group 3) countries in Africa. The future losses were discounted to their present values at a 3% discount rate. The model was re-analysed using 5% and 10% discount rates to assess the impact on the estimated total value of human lives lost., Results: The estimated value of 67 860 human lives lost in 2015 due to NTDs was Int$ 5 112 472 607. Out of that, 14.6% was borne by Group 1, 57.7% by Group 2 and 27.7% by Group 3 countries. The mean value of human life lost per NTD death was Int$ 231 278, Int$ 109 771 and Int$ 37 489 for Group 1, Group 2 and Group 3 countries, respectively. The estimated value of human lives lost in 2015 due to NTDs was equivalent to 0.1% of the cumulative gross domestic product of the 53 continental African countries., Conclusions: Even though NTDs are not a major cause of death, they impact negatively on the productivity of those affected throughout their life-course. Thus, the case for investing in NTDs control should also be influenced by the value of NTD morbidity, availability of effective donated medicines, human rights arguments, and need to achieve the NTD-related target 3.3 of the United Nations Sustainable Development Goal 3 (on health) by 2030.

Background: A functional national health research system (NHRS) is crucial in strengthening a country's health system to promote, restore and maintain the health status of its population. Progress towards the goal of universal health coverage in the post-2015 sustainable development agenda will be difficult for African countries without strengthening of their NHRS to yield the required evidence for decision-making. This study aims to develop a barometer to facilitate monitoring of the development and performance of NHRSs in the African Region of WHO., Methods: The African national health research systems barometer algorithm was developed in response to a recommendation of the African Advisory Committee for Health Research and Development of WHO. Survey data collected from all the 47 Member States in the WHO African Region using a questionnaire were entered into an Excel spreadsheet and analysed. The barometer scores for each country were calculated and the performance interpreted according to a set of values ranging from 0% to 100%., Results: The overall NHRS barometer score for the African Region was 42%, which is below the average of 50%. Among the 47 countries, the average NHRS performance was less than 20% in 10 countries, 20-40% in 11 countries, 41-60% in 16 countries, 61-80% in nine countries, and over 80% in one country. The performance of NHRSs in 30 (64%) countries was below 50%., Conclusion: An African NHRS barometer with four functions and 17 sub-functions was developed to identify the gaps in and facilitate monitoring of NHRS development and performance. The NHRS scores for the individual sub-functions can guide policymakers to locate sources of poor performance and to design interventions to address them.

Background: The Global Forum 2015 panel session dialogue entitled "From evidence to policy - thinking outside the box" was held on 26 August 2015 in the Philippines to debate why evidence was not fully translated into policy and practice and what could be done to increase its uptake. This paper reports the reasons and possible actions for increasing the uptake of evidence, and highlights the actions partners could take to increase the use of evidence in the African Region., Discussion: The Global Forum 2015 debate attributed African Region's low uptake of evidence to the big gap in incentives and interests between research for health researchers and public health policy-makers; limited appreciation on the side of researchers that public health decisions are based on multiple and complex considerations; perception among users that research evidence is not relevant to local contexts; absence of knowledge translation platforms; sub-optimal collaboration and engagement between industry and research institutions; lack of involvement of civil society organizations; lack of engagement of communities in the research process; failure to engage the media; limited awareness and debate in national and local parliaments on the importance of investing in research and innovation; and dearth of research and innovation parks in the African Region., Conclusion: The actions needed in the Region to increase the uptake of evidence in policy and practice include strengthening NHRS governance; bridging the motivation gap between researchers and health policy-makers; restoring trust between researchers and decision-makers; ensuring close and continuous intellectual intercourse among researchers, ministry of health policy-makers and technocrats during the life course of research projects or programmes; proactive collaboration between academia and industry; regular briefings of civil society, media, relevant parliamentary committees and development partners; development of vibrant knowledge translation platforms; development of action plans for implementing research recommendations, preferably in the context of the Sustainable Development Goals; and encouragement of competition on NHRS strengthening and research output and uptake among the countries using a barometer or scorecard to review their performance at various regional ministerial forums and taking into account the lessons learned from the MDG period.

Background: Majority of the countries in the World Health Organization (WHO) African Region are not on track to achieve the health-related Millennium Development Goals, yet even more ambitious Sustainable Development Goals (SDGs), including SDG 3 on heath, have been adopted. This paper highlights the challenges - amplified by the recent Ebola virus disease (EVD) outbreak in West Africa - that require WHO and other partners' dialogue in support of the countries, and debate on how WHO can leverage the existing space and place to foster health development dialogues in the Region., Discussion: To realise SDG 3 on ensuring healthy lives and promoting well-being for all at all ages, the African Region needs to tackle the persistent weaknesses in its health systems, systems that address the social determinants of health and national health research systems. The performance of the third item is crucial for the development and innovation of systems, products and tools for promoting, maintaining and restoring health in an equitable manner. Under its new leadership, the WHO Regional Office for Africa is transforming itself to galvanise existing partnerships, as well as forging new ones, with a view to accelerating the provision of timely and quality support to the countries in pursuit of SDG 3. WHO in the African Region engages in dialogues with various stakeholders in the process of health development. The EVD outbreak in West Africa accentuated the necessity for optimally exploiting currently available space and place for health development discourse. There is urgent need for the WHO Regional Office for Africa to fully leverage the space and place arenas of the World Health Assembly, WHO Regional Committee for Africa, African Union, Regional economic communities, Harmonization for Health in Africa, United Nations Economic Commission for Africa, African Development Bank, professional associations, and WHO African Health Forum, when it is created, for dialogues to mobilise the required resources to give the African Region the thrust it needs to attain SDG 3., Conclusions: The pursuit of SDG 3 amidst multiple challenges related to political leadership and governance, weak health systems, sub-optimal systems for addressing the socioeconomic determinants of health, and weak national health research systems calls for optimum use of all the space and place available for regional health development dialogues to supplement Member States' efforts.

Background: This paper has three objectives: to review the health development landscape in the World Health Organization African Region, to discuss the role of health policy dialogue in improving harmonisation and alignment to national health policies and strategic plans, and to provide an analytical view of the critical factors in realising a good outcome from a health policy dialogue process., Discussion: Strengthening policy dialogue to support the development and implementation of robust and comprehensive national health policies and plans, as well as to improve aid effectiveness, is seen as a strategic entry point to improving health sector results. However, unbalanced power relations, the lack of contextualised and relevant evidence, the diverse interests of the actors involved, and the lack of conceptual clarity on what policy dialogue entails impact the outcomes of a policy dialogue process. The critical factors for a successful policy dialogue have been identified as adequate preparation; secured time and resources to facilitate an open, inclusive and informed discussion among the stakeholders; and stakeholders' monitoring and assessment of the dialogue's activities for continued learning. Peculiarities of low income countries pose a challenge to their policy dialogue processes, including the chaotic-policy making processes, the varied capacity of the actors and donor dependence., Conclusion: Policy dialogue needs to be appreciated as a complex and iterative process that spans the whole process of policy-making, implementation, review and monitoring, and subsequent policy revisions. The existence of the critical factors for a successful policy dialogue process needs to be ensured whilst paying special attention to the peculiarities of low income countries and potential power relations, and mitigating the possible negative consequences. There is need to be cognisant of the varied capacities and interests of stakeholders and the need for capacity building, and to put in place mechanisms to manage conflict of interest. The likelihood of a favourable outcome from a policy dialogue process will depend on the characteristics of the issue under consideration and whether it is contested or not, and the policy dialogue process needs to be tailored accordingly.

Background: In 2014, almost half of the global tuberculosis deaths occurred in the World Health Organization (WHO) African Region. Approximately 21.5 % of the 6 060 742 TB cases (new and relapse) reported to the WHO in 2014 were in the African Region. The specific objective of this study was to estimate future gross domestic product (GDP) losses associated with TB deaths in the African Region for use in advocating for better strategies to prevent and control tuberculosis., Methods: The cost-of-illness method was used to estimate non-health GDP losses associated with TB deaths. Future non-health GDP losses were discounted at 3 %. The analysis was conducted for three income groups of countries. One-way sensitivity analysis at 5 and 10 % discount rates was undertaken to assess the impact on the expected non-health GDP loss., Results: The 0.753 million tuberculosis deaths that occurred in the African Region in 2014 would be expected to decrease the future non-health GDP by International Dollars (Int$) 50.4 billion. Nearly 40.8, 46.7 and 12.5 % of that loss would come from high and upper-middle- countries or lower-middle- and low-income countries, respectively. The average total non-health GDP loss would be Int$66 872 per tuberculosis death. The average non-health GDP loss per TB death was Int$167 592 for Group 1, Int$69 808 for Group 2 and Int$21 513 for Group 3., Conclusion: Tuberculosis exerts a sizeable economic burden on the economies of the WHO AFR countries. This implies the need to strongly advocate for better strategies to prevent and control tuberculosis and to help countries end the epidemic of tuberculosis by 2030, as envisioned in the United Nations General Assembly resolution on Sustainable Development Goals (SDGs).

Background: Out-of-pocket payments in health care have been shown to impose significant burden on households in Sub-Saharan Africa, leading to constrained access to health care and impoverishment. In an effort to reduce the financial burden imposed on households by user fees, some countries in Sub-Saharan Africa have abolished user fees in the health sector. Zambia is one of few countries in Sub-Saharan Africa to abolish user fees in primary health care facilities with a view to alleviating financial burden of out-of-pocket payments among the poor. The main aim of this paper was to examine the extent and patterns of financial protection from fees following the decision to abolish user fees in public primary health facilities., Methods: Our analysis is based on a nationally representative health expenditure and utilization survey conducted in 2014. We calculated the incidence and intensity of catastrophic health expenditure based on households' out-of-pocket payments during a visit as a percentage of total household consumption expenditure. We further show the intensity of the problem of catastrophic health expenditure (CHE) experienced by households., Results: Our analysis show that following the removal of user fees, a majority of patients who visited public health facilities benefitted from free care at the point of use. Further, seeking care at public primary health facilities is associated with a reduced likelihood of incurring CHE after controlling for economic wellbeing and other covariates. However, 10% of households are shown to suffer financial catastrophe as a result of out-of-pocket payments. Further, there is considerable inequality in the incidence of CHE whereby the poorest expenditure quintile experienced a much higher incidence., Conclusion: Despite the removal of user fees at primary health care level, CHE is high among the poorest sections of the population. This study also shows that cost of transportation is mainly responsible for limiting the protective effectiveness of user fee removal on CHE among particularly poorest households.

Background: The increasing emphasis on research, development and innovation for health in providing solutions to the high burden of diseases in the African Region has warranted a proliferation of studies including clinical trials. This changing public health landscape requires that countries develop adequate ethics review capacities to protect and minimize risks to study participants. Therefore, this study assessed the readiness of national ethics committees to respond to challenges posed by a globalized biomedical research system which is constantly challenged by new public health threats, rapid scientific and technological advancements affecting biomedical research and development, delivery and manufacture of vaccines and therapies, and health technology transfer., Methods: This is a descriptive study, which used a questionnaire structured to elicit information on the existence of relevant national legal frameworks, mechanisms for ethical review; as well as capacity requirements for national ethics committees. The questionnaire was available in English and French and was sent to 41 of the then 46 Member States of the WHO African Region, excluding the five Lusophone Member States. Information was gathered from senior officials in ministries of health, who by virtue of their offices were considered to have expert knowledge of research ethics review systems in their respective countries., Results: Thirty three of the 41 countries (80.5 %) responded. Thirty (90.9 %) of respondent countries had a national ethics review committee (NEC); 79 % of which were established by law. Twenty-five (83.3 %) NECs had secretarial and administrative support. Over 50 % of countries with NECs indicated a need for capacity strengthening through periodic training on international guidelines for health research (including clinical trials) ethics; and allocation of funds for administrative and secretariat support., Conclusions: Despite the existing training initiatives, the Region still experiences a shortage of professionals trained in health research ethics/ethicists. Committees continue to face various capacity needs especially for evaluating clinical trials, for monitoring ongoing research, database management and for accrediting institutional ethics committees. Given the growing number of clinical trials involving human participants in the African Region, there is urgent need for supporting countries without NECs to establish them; capacity strengthening where they exist; and creation of a regional network and joint ethical review mechanisms, whose membership would be open to all NECs of the Region.

Background: Worldwide, a total of 6.282 million deaths occurred among children aged less than 5 years in 2013. About 47.4 % of those were borne by the 47 Member States of the World Health Organization (WHO) African Region. Sadly, even as we approach the end date for the 2015 Millennium Development Goals (MDGs), only eight African countries are on track to achieve the MDG 4 target 4A of reducing under-five mortality by two thirds between 1990 and 2015. The post-2015 Sustainable Development Goal (SDG) 3 target is "by 2030, end preventable deaths of new-borns and children under 5 years of age". There is urgent need for increased advocacy among governments, the private sector and development partners to provide the resources needed to build resilient national health systems to deliver an integrated package of people-centred interventions to end preventable child morbidity and mortality and other structures to address all the basic needs for a healthy population. The specific objective of this study was to estimate expected/future productivity losses from child deaths in the WHO African Region in 2013 for use in advocacy for increased investments in child health services and other basic services that address children's welfare., Methods: A cost-of-illness method was used to estimate future non-health GDP losses related to child deaths. Future non-health GDP losses were discounted at 3 %. The analysis was undertaken with the countries categorized under three income groups: Group 1 consisted of nine high and upper middle income countries, Group 2 of 13 lower middle income countries, and Group 3 of 25 low income countries. One-way sensitivity analysis at 5 % and 10 % discount rates assessed the impact of the expected non-health GDP loss., Results: The discounted value of future non-health GDP loss due to the deaths of children under 5 years old in 2013 will be in the order of Int$ 150.3 billion. Approximately 27.3 % of the loss will be borne by Group 1 countries, 47.1 % by Group 2 and 25.7 % by Group 3. The average non-health GDP lost per child death will be Int$ 174 310 for Group 1, Int$ 57 584 for Group 2 and Int$ 25 508 for Group 3., Conclusions: It is estimated that the African Region will incur a loss of approximately 6 % of its non-health GDP from the future years of life lost among the 2 976 000 child deaths that occurred in 2013. Therefore, countries and development partners should in solidarity sustainably provide the resources essential to build resilient national health systems and systems to address the determinants of health and meet the other basic needs such as for clothing, education, food, shelter, sanitation and clean water to end preventable child morbidity and mortality.

Background: A number of resolutions of the World Health Assembly and the WHO Regional Committee for Africa call upon African countries and their development partners to make the required investments in national health research systems (NHRS) to generate knowledge and promote its use in tackling priority public health challenges. Implementation of these resolutions is critical for Africa to progress with the rest of the world in achieving the post-2015 health sustainable development goal. This study assesses the current status of some NHRS components in the 47 countries of the WHO African Region, identifies the factors that enable and constrain NHRS, and proposes the way forward., Methods: To track progress in NHRS components and for comparison, a questionnaire that was used in NHRS surveys in 2003 and 2009 was administered in all 47 countries in the African Region. The national health research focal persons were responsible for completing the questionnaire, which had been hand-delivered to them by the WHO country office staff in charge of research, who also briefed them on the survey, went through the questionnaire for clarity, and sought their informed consent., Results: All the 47 countries responded to the questionnaire, but some did not answer all questions. Of the countries responding to various questions 49 % (23/47) had a national health research policy; 47 % (22/47) had a health strategic plan; 40 % (19/47) had legislation governing research; 53 % (25/47) had a national health research priority agenda; 51 % (24/47) reported having a functional NHRS and a national health research management forum; 91 % (43/47) had an ethical review committee; 49 % (23/47) had hospitals with ethical review committees to review clinical research proposals; 51 % (24/47) had a scientific review committee; 62 % (29/47) had health institutions with scientific review committees; 83 % (39/47) had a national health research focal point; 51 % (24/47) had a health research programme; 55 % (26/47) had a national health or medical research institute or council; 93 % (41/44) had at least one university faculty of health sciences that conducted health research; and 33 % (15/46) had a knowledge translation platform. Forty-seven percent of countries reported having a budget line for research for health in the ministry of health budget. Between 2003 and 2014, the countries with a functional NHRS increased from 30 % to 51 %., Conclusion: Compared with 2003 and 2009 surveys, our survey found many countries to have made progress in strengthening some of the functions of their NHRS. However, there remains an urgent need for countries without NHRS to establish them and for others to improve the functionality and efficiency of every NHRS component. This is necessary for the national governments to effectively execute their leadership and governance of NHRS and to create an enabling environment within which research for health can flourish.

Background: By 28 June 2015, there were a total of 11,234 deaths from the Ebola virus disease (EVD) in five West African countries (Guinea, Liberia, Mali, Nigeria and Sierra Leone). The objective of this study was to estimate the future productivity losses associated with EVD deaths in these West African countries, in order to encourage increased investments in national health systems., Methods: A cost-of-illness method was employed to calculate future non-health (NH) gross domestic product (GDP) (NHGDP) losses associated with EVD deaths. The future non-health GDP loss (NHGDPLoss) was discounted at 3 %. Separate analyses were done for three different age groups (< =14 years, 15-44 years and = >45 years) for the five countries (Guinea, Liberia, Mali, Nigeria, and Sierra Leone) affected by EVD. We also conducted a one-way sensitivity analysis at 5 and 10 % discount rates to gauge their impacts on expected NHGDPLoss., Results: The discounted value of future NHGDPLoss due to the 11,234 deaths associated with EVD was estimated to be Int$ (international dollars) 155,663,244. About 27.86 % of the loss would be borne by Guinea, 34.84 % by Liberia, 0.10 % by Mali, 0.24 % by Nigeria and 36.96 % by Sierra Leone. About 27.27 % of the loss is attributed to those aged under 14 years, 66.27 % to those aged 15-44 years and 6.46 % to those aged over 45 years. The average NHGDPLoss per EVD death was estimated to be Int$ 17,473 for Guinea, Int$ 11,283 for Liberia, Int$ 25,126 for Mali, Int$ 47,364 for Nigeria and Int$ 14,633 for Sierra Leone., Conclusion: In spite of alluded limitations, the estimates of human and economic losses reported in this paper, in addition to those projected by the World Bank, show that EVD imposes a significant economic burden on the affected West African countries. That heavy burden, coupled with human rights and global security concerns, underscores the urgent need for increased domestic and external investments to enable Guinea, Liberia and Sierra Leone (and other vulnerable African countries) to develop resilient health systems, including core capacities to detect, assess, notify, verify and report events, and to respond to public health risks and emergencies.

Background: Several instruments at both the global and regional levels to which countries in the WHO African Region are party call for action by governments to strengthen national health research systems (NHRS). This paper debates the extent to which Malawi has fulfilled this commitment., Discussion: Some research literature has characterized African research - and by implication NHRS - as moribund. In our view, the Malawi government, with partner support, has made effort to strengthen the capacities of individuals and institutions that generate scientific knowledge. This is reflected in the Malawi national NHRS index (MNSR4HI) of 51%, which is within the 50%-69% range, and thus, it should be characterized as tepid with significant potential to flourish. Governance of research for health (R4H) has improved with the promulgation of the Malawi Science and Technology Act in 2003. However, lack of an explicit R4H policy, a strategic plan and a national R4H management forum undermines the government's effectiveness in overseeing the operation of the NHRS. The mean index of 'governance of R4H' sub-functions was 67%, implying that research governance is tepid. Malawi has a national health research focal point, an R4H program, and four public and 11 private universities. The average index of 'creating and sustaining resources' sub-functions was 48.6%, meaning that R4H human and infrastructural resources can be considered to be in a moribund state. The average index of 'producing and using research' sub-functions of 50.4% implies that production and utilization of research findings in policy development and public health practice can best be described as tepid. Efforts need to be intensified to boost national research productivity. Over the five financial years 2011-2016 the government plans to spend 0.26% of its total health budget on R4H. The mean index of 'financing' sub-functions of 23.6% is within the range of 1-49%, which is considered moribund. A functional NHRS is a prerequisite for the achievement of the health system goal of universal health coverage. Malawi, like majority of African countries, needs to invest more in strengthening R4H governance, developing and sustaining R4H resources, and producing and using research findings.

Background: This study focused on the 47 Member States of the World Health Organization (WHO) African Region. The specific objectives were to prepare a synthesis on the situation of health systems' components, to analyse the correlation between the interventions related to the health Millennium Development Goals (MDGs) and some health systems' components and to provide overview of four major thrusts for progress towards universal health coverage (UHC)., Methods: The WHO health systems framework and the health-related MDGs were the frame of reference. The data for selected indicators were obtained from the WHO World Health Statistics 2014 and the Global Health Observatory., Results: African Region's average densities of physicians, nursing and midwifery personnel, dentistry personnel, pharmaceutical personnel, and psychiatrists of 2.6, 12, 0.5, 0.9 and 0.05 per 10 000 population were about five-fold, two-fold, five-fold, five-fold and six-fold lower than global averages. Fifty-six percent of the reporting countries had fewer than 11 health posts per 100 000 population, 88% had fewer than 11 health centres per 100 000 population, 82% had fewer than one district hospital per 100 000 population, 74% had fewer than 0.2 provincial hospitals per 100 000 population, and 79% had fewer than 0.2 tertiary hospitals per 100 000 population. Some 83% of the countries had less than one MRI per one million people and 95% had fewer than one radiotherapy unit per million population. Forty-six percent of the countries had not adopted the recommendation of the International Taskforce on Innovative Financing to spend at least US$ 44 per person per year on health. Some of these gaps in health system components were found to be correlated to coverage gaps in interventions for maternal health (MDG 5), child health (MDG 4) and HIV/AIDS, TB and malaria (MDG 6)., Conclusions: Substantial gaps exist in health systems and access to MDG-related health interventions. It is imperative that countries adopt the 2014 Luanda Commitment on UHC in Africa as their long-term vision and back it with sound policies and plans with clearly engrained road maps for strengthening national health systems and addressing the social determinants of health.

Background: An estimated 147,741 maternal deaths occurred in 2010 in 45 of the 47 countries in the African Region of the World Health Organization (WHO). The objective of this study was to estimate the indirect cost of maternal deaths in the Region to provide data for use in advocacy for increased domestic and external investment in multisectoral policy interventions to curb maternal mortality., Methods: This study used the cost-of-illness method to estimate the indirect cost of maternal mortality, i.e. the loss in non-health gross domestic product (GDP) attributable to maternal deaths. Estimates on maternal mortality for 2010 from Trends in maternal mortality: 1990 to 2010 published by WHO, UNICEF, UNFPA and the World Bank were used in these calculations. Values for future non-health GDP lost were converted into their present values by applying a 3% discount rate. One-way sensitivity analysis at 5% and 10% discount rates assessed the impact on non-health GDP loss. Indirect cost analysis was undertaken for the countries, categorized under three income groups. Group 1 consisted of nine high and upper middle income countries, Group 2 of 12 lower middle income countries, and Group 3 of 26 low income countries. Estimates for Seychelles in Group 1 and South Sudan in Group 3 were not provided in the source used., Results: The 147,741 maternal deaths that occurred in 45 countries in the African Region in 2010 resulted in a total non-health GDP loss of Int$ 4.5 billion (PPP). About 24.5% of the loss was in Group 1 countries, 44.9% in Group 2 countries and 30.6% in Group 3 countries. This translated into losses in non-health GDP of Int$ 139,219, Int$ 35,440 and Int$ 16,397 per maternal death, respectively, for the three groups. Using discount rates of 5% and 10% reduced the total non-health GDP loss by 19.1% and 47.7%, respectively., Conclusion: Maternal mortality is responsible for a noteworthy level of non-health GDP loss among the countries in the African Region. There is urgent need, therefore, to increase domestic and external investment to scale up coverage of existing cost-effective, multisectoral women's health interventions to reduce maternal morbidity and mortality.

Background: In order to measure and analyse the technical efficiency of district hospitals in Ghana, the specific objectives of this study were to (a) estimate the relative technical and scale efficiency of government, mission, private and quasi-government district hospitals in Ghana in 2005; (b) estimate the magnitudes of output increases and/or input reductions that would have been required to make relatively inefficient hospitals more efficient; and (c) use Tobit regression analysis to estimate the impact of ownership on hospital efficiency., Methods: In the first stage, we used data envelopment analysis (DEA) to estimate the efficiency of 128 hospitals comprising of 73 government hospitals, 42 mission hospitals, 7 quasi-government hospitals and 6 private hospitals. In the second stage, the estimated DEA efficiency scores are regressed against hospital ownership variable using a Tobit model. This was a retrospective study., Results: In our DEA analysis, using the variable returns to scale model, out of 128 district hospitals, 31 (24.0%) were 100% efficient, 25 (19.5%) were very close to being efficient with efficiency scores ranging from 70% to 99.9% and 71 (56.2%) had efficiency scores below 50%. The lowest-performing hospitals had efficiency scores ranging from 21% to 30%.Quasi-government hospitals had the highest mean efficiency score (83.9%) followed by public hospitals (70.4%), mission hospitals (68.6%) and private hospitals (55.8%). However, public hospitals also got the lowest mean technical efficiency scores (27.4%), implying they have some of the most inefficient hospitals.Regarding regional performance, Northern region hospitals had the highest mean efficiency score (83.0%) and Volta Region hospitals had the lowest mean score (43.0%).From our Tobit regression, we found out that while quasi-government ownership is positively associated with hospital technical efficiency, private ownership negatively affects hospital efficiency., Conclusions: It would be prudent for policy-makers to examine the least efficient hospitals to correct widespread inefficiency. This would include reconsidering the number of hospitals and their distribution, improving efficiency and reducing duplication by closing or scaling down hospitals with efficiency scores below a certain threshold. For private hospitals with inefficiency related to large size, there is a need to break down such hospitals into manageable sizes.

Background: The target date for achieving the Millennium Development Goals (MDGs) is now closer than ever. There is lack of sufficient progress in achieving the MDG targets in many low- and middle-income countries. Furthermore, there has also been concerns about wide spread inequity among those that are on track to achieve the health-related MDGs. Bangladesh has made a notable progress towards achieving the MDG 5 targets. It is, however, important to assess if this is an inclusive and equitable progress, as inequitable progress may not lead to sustainable health outcomes. The objective of this study is to assess the magnitude of inequities in reproductive and maternal health services in Bangladesh and propose relevant recommendations for decision making., Methods: The 2007 Bangladesh demographic and health survey data is analyzed for inequities in selected maternal and reproductive health interventions using the slope and relative indices of inequality., Results: The analysis indicates that there are significant wealth-related inequalities favouring the wealthiest of society in many of the indicators considered. Antenatal care (at least 4 visits), antenatal care by trained providers such as doctors and nurses, content of antenatal care, skilled birth attendance, delivery in health facility and delivery by caesarean section all manifest inequities against the least wealthy. There are no wealth-related inequalities in the use of modern contraception. In contrast, less desired interventions such as delivery by untrained providers and home delivery show wealth-related inequalities in favour of the poor., Conclusions: For an inclusive and sustainable improvement in maternal and reproductive health outcomes and achievement of MDG 5 targets, it essential to address inequities in maternal and reproductive health interventions. Under the government's stewardship, all stakeholders should accord priority to tackling wealth-related inequalities in maternal and reproductive health services by implementing equity-promoting measures both within and outside the health sector.

Background: The objectives of this study were to assess the patterns of treatment seeking behaviour for children under five with malaria; and to examine the statistical relationship between out-of-pocket expenditure (OOP) on malaria treatment for under-fives and source of treatment, place of residence, education and wealth characteristics of Uganda households. OOP expenditure on health care is now a development concern due to its negative effect on households' ability to finance consumption of other basic needs., Methods: The 2009 Uganda Malaria Indicator Survey was the source of data on treatment seeking behaviour for under-five children with malaria, and patterns and levels of OOP expenditure for malaria treatment. Binomial logit and Log-lin regression models were estimated. In logit model the dependent variable was a dummy (1=incurred some OOP, 0=none incurred) and independent variables were wealth quintiles, rural versus urban, place of treatment, education level, sub-region, and normal duty disruption. The dependent variable in Log-lin model was natural logarithm of OOP and the independent variables were the same as mentioned above., Results: Five key descriptive analysis findings emerge. First, malaria is quite prevalent at 44.7% among children below the age of five. Second, a significant proportion seeks treatment (81.8%). Third, private providers are the preferred option for the under-fives for the treatment of malaria. Fourth, the majority pay about 70.9% for either consultation, medicines, transport or hospitalization but the biggest percent of those who pay, do so for medicines (54.0%). Fifth, hospitalization is the most expensive at an average expenditure of US$7.6 per child, even though only 2.9% of those that seek treatment are hospitalized.The binomial logit model slope coefficients for the variables richest wealth quintile, Private facility as first source of treatment, and sub-regions Central 2, East central, Mid-eastern, Mid-western, and Normal duties disrupted were positive and statistically significant at 99% level of confidence. On the other hand, the Log-lin model slope coefficients for Traditional healer, Sought treatment from one source, Primary educational level, North East, Mid Northern and West Nile variables had a negative sign and were statistically significant at 95% level of confidence., Conclusion: The fact that OOP expenditure is still prevalent and private provider is the preferred choice, increasing public provision may not be the sole answer. Plans to improve malaria treatment should explicitly incorporate efforts to protect households from high OOP expenditures. This calls for provision of subsidies to enable the private sector to reduce prices, regulation of prices of malaria medicines, and reduction/removal of import duties on such medicines.

Background: Eritrean gross national income of Int$610 per capita is lower than the average for Africa (Int$1620) and considerably lower than the global average (Int$6977). It is therefore imperative that the country's resources, including those specifically allocated to the health sector, are put to optimal use. The objectives of this study were (a) to estimate the relative technical and scale efficiency of public secondary level community hospitals in Eritrea, based on data generated in 2007, (b) to estimate the magnitudes of output increases and/or input reductions that would have been required to make relatively inefficient hospitals more efficient, and (c) to estimate using Tobit regression analysis the impact of institutional and contextual/environmental variables on hospital inefficiencies., Methods: A two-stage Data Envelopment Analysis (DEA) method is used to estimate efficiency of hospitals and to explain the inefficiencies. In the first stage, the efficient frontier and the hospital-level efficiency scores are first estimated using DEA. In the second stage, the estimated DEA efficiency scores are regressed on some institutional and contextual/environmental variables using a Tobit model. In 2007 there were a total of 20 secondary public community hospitals in Eritrea, nineteen of which generated data that could be included in the study. The input and output data were obtained from the Ministry of Health (MOH) annual health service activity report of 2007. Since our study employs data that are five years old, the results are not meant to uncritically inform current decision-making processes, but rather to illustrate the potential value of such efficiency analyses., Results: The key findings were as follows: (i) the average constant returns to scale technical efficiency score was 90.3%; (ii) the average variable returns to scale technical efficiency score was 96.9%; and (iii) the average scale efficiency score was 93.3%. In 2007, the inefficient hospitals could have become more efficient by either increasing their outputs by 20,611 outpatient visits and 1,806 hospital discharges, or by transferring the excess 2.478 doctors (2.85%), 9.914 nurses and midwives (0.98%), 9.774 laboratory technicians (9.68%), and 195 beds (10.42%) to primary care facilities such as health centres, health stations, and maternal and child health clinics. In the Tobit regression analysis, the coefficient for OPDIPD (outpatient visits as a proportion of inpatient days) had a negative sign, and was statistically significant; and the coefficient for ALOS (average length of stay) had a positive sign, and was statistically significant at 5% level of significance., Conclusions: The findings from the first-stage analysis imply that 68% hospitals were variable returns to scale technically efficient; and only 42% hospitals achieved scale efficiency. On average, inefficient hospitals could have increased their outpatient visits by 5.05% and hospital discharges by 3.42% using the same resources. Our second-stage analysis shows that the ratio of outpatient visits to inpatient days and average length of inpatient stay are significantly correlated with hospital inefficiencies. This study shows that routinely collected hospital data in Eritrea can be used to identify relatively inefficient hospitals as well as the sources of their inefficiencies.

Background: In order to raise African countries probability of achieving the United Nations Millennium Development Goals by 2015, there is need to increase and more efficiently use domestic and external funding to strengthen health systems infrastructure in order to ensure universal access to quality health care. The objective of this paper is to examine the changes that have occurred in African countries on health financing, taking into account the main sources of funding over the period 2000 to 2009., Methods: Our analysis is based on the National Health Accounts (NHA) data for the 46 countries of the WHO African Region. The data were obtained from the WHO World Health Statistics Report 2012. Data for Zimbabwe was not available. The analysis was done using Excel software., Results: Between 2000 and 2009, number of countries spending less than 5% of their GDP on health decreased from 24 to 17; government spending on health as a percentage of total health expenditure increased in 31 countries and decreased in 13 countries; number of countries allocating at least 15% of national budgets on health increased from 2 to 4; number of countries partially financing health through social security increased from 19 to 21; number of countries where private spending was 50% and above of total health expenditure decreased from 29 (64%) to 23 (51%); over 70% of private expenditure on health came from household out-of-pocket payments (OOPS) in 32 (71%) countries and in 27 (60%) countries; number of countries with private prepaid plans increased from 29 to 31; number of countries financing more than 20% of their total health expenditure from external sources increased from 14 to 19; number of countries achieving the Commission for Macroeconomics and Health recommendation of spending at least US$34 per person per year increased from 11 to 29; number of countries achieving the International Taskforce on Innovative Financing recommendation of spending at least US$44 per person per year increased from 11 to 24; average per capita total expenditure on health increased from US$35 to US$82; and average per capita government expenditure on health grew from US$ 15 to US$ 41., Conclusion: Whilst the African Region (AFR) average government expenditure on health as a per cent of THE increased by 5.4 per cent, the average private health expenditure decreased by the same percentage between 2000 and 2009. The regional average OOPS as a per cent of private expenditure on health increased by 4.9 per cent. The average external resources for health as a percentage of THE increased by 3.7 per cent. Even though on average the quantity of health funds have increased, we cannot judge from the current study the extent to which financial risk protection, equity and efficiency has progressed or regressed.In 2009 OOPS made up over 20% of total expenditure on health in 34 countries. Evidence shows that where OOPS as a percentage of total health expenditure is less than 20%, the risk of catastrophic expenditure is negligible. Therefore, there is urgent need for countries to develop health policies that address inequities and health financing models that optimize the use of health resources and strengthen health infrastructure. Increased coverage of prepaid health-financing mechanisms would reduce over-reliance on potentially catastrophic and impoverishing out-of-pocket payments.

Background: The 58th World Health Assembly and 56th WHO Regional Committee for Africa adopted resolutions urging Member States to ensure that health financing systems included a method for prepayment to foster financial risk sharing among the population and avoid catastrophic health-care expenditure. The Regional Committee asked countries to strengthen or develop comprehensive health financing policies. This paper presents the findings of a survey conducted among senior staff of selected Eritrean ministries and agencies to elicit views on some of the elements likely to be part of a national health financing policy., Methods: This is a descriptive study. A questionnaire was prepared and sent to 19 senior staff (Directors) in the Ministry of Health, Labour Department, Civil Service Administration, Eritrean Confederation of Workers, National Insurance Corporation of Eritrea and Ministry of Local Government. The respondents were selected by the Ministry of Health as key informants., Results: The key findings were as follows: the response rate was 84.2% (16/19); 37.5% (6/16) and 18.8% said that the vision of Eritrean National Health Financing Policy (NHFP) should include the phrases 'equitable and accessible quality health services' and 'improve efficiency or reduce waste' respectively; over 68% indicated that NHFP should include securing adequate funding, ensuring efficiency, ensuring equitable financial access, protection from financial catastrophe, and ensuring provider payment mechanisms create positive incentives to service providers; over 80% mentioned community participation, efficiency, transparency, country ownership, equity in access, and evidence-based decision making as core values of NHFP; over 62.5% confirmed that NHFP components should consist of stewardship (oversight), revenue collection, revenue pooling and risk management, resource allocation and purchasing of health services, health economics research, and development of human resources for health; over 68.8% indicated cost-sharing, taxation and social health insurance as preferred revenue collection mechanisms; and 68.75% indicated their preferred provider payment mechanism to be a global (lump sum) budget., Conclusion: This study succeeded in gathering the preliminary views of senior staff of selected Eritrean ministries and agencies regarding the likely elements of the NHFP, i.e. the vision, objectives, components, provider payment mechanisms, and health financing agency and its governance. In addition to stakeholder surveys, it would be helpful to inform the development of the NHFP with other pieces of evidence, including cost-effectiveness analysis of health services and interventions, financial feasibility analysis of financing options, a survey of the political and professional acceptability of financing options, national health accounts, and equity analyses.

Background: With the date for achieving the targets of the Millennium Development Goals (MDGs) approaching fast, there is a heightened concern about equity, as inequities hamper progress towards the MDGs. Equity-focused approaches have the potential to accelerate the progress towards achieving the health-related MDGs faster than the current pace in a more cost-effective and sustainable manner. Ghana's rate of progress towards MDGs 4 and 5 related to reducing child and maternal mortality respectively is less than what is required to achieve the targets. The objective of this paper is to examine the equity dimension of child and maternal health outcomes and interventions using Ghana as a case study., Methods: Data from Ghana Demographic and Health Survey 2008 report is analyzed for inequities in selected maternal and child health outcomes and interventions using population-weighted, regression-based measures: slope index of inequality and relative index of inequality., Results: No statistically significant inequities are observed in infant and under-five mortality, perinatal mortality, wasting and acute respiratory infection in children. However, stunting, underweight in under-five children, anaemia in children and women, childhood diarrhoea and underweight in women (BMI < 18.5) show inequities that are to the disadvantage of the poorest. The rates significantly decrease among the wealthiest quintile as compared to the poorest. In contrast, overweight (BMI 25-29.9) and obesity (BMI ≥ 30) among women reveals a different trend - there are inequities in favour of the poorest. In other words, in Ghana overweight and obesity increase significantly among women in the wealthiest quintile compared to the poorest. With respect to interventions: treatment of diarrhoea in children, receiving all basic vaccines among children and sleeping under ITN (children and pregnant women) have no wealth-related gradient. Skilled care at birth, deliveries in a health facility (both public and private), caesarean section, use of modern contraceptives and intermittent preventive treatment for malaria during pregnancy all indicate gradients that are in favour of the wealthiest. The poorest use less of these interventions. Not unexpectedly, there is more use of home delivery among women of the poorest quintile., Conclusion: Significant Inequities are observed in many of the selected child and maternal health outcomes and interventions. Failure to address these inequities vigorously is likely to lead to non-achievement of the MDG targets related to improving child and maternal health (MDGs 4 and 5). The government should therefore give due attention to tackling inequities in health outcomes and use of interventions by implementing equity-enhancing measure both within and outside the health sector in line with the principles of Primary Health Care and the recommendations of the WHO Commission on Social Determinants of Health.

Background: The burden of malaria is a key challenge to both human and economic development in malaria endemic countries. The impact of malaria can be categorized from three dimensions, namely: health, social and economic. The objective of this study was to estimate the impact of malaria morbidity on gross domestic product (GDP) of Uganda., Methods: The impact of malaria morbidity on GDP of Uganda was estimated using double-log econometric model. The 1997-2003 time series macro-data used in the analysis were for 28 quarters, i.e. 7 years times 4 quarters per year. It was obtained from national and international secondary sources., Results: The slope coefficient for Malaria Index (M) was -0.00767; which indicates that when malaria morbidity increases by one unit, while holding all other explanatory variables constant, per capita GDP decreases by US$0.00767 per year. In 2003 Uganda lost US$ 49,825,003 of GDP due to malaria morbidity. Dividing the total loss of US$49.8 million by a population of 25,827,000 yields a loss in GDP of US$1.93 per person in Uganda in 2003., Conclusion: Malaria morbidity results in a substantive loss in GDP of Uganda. The high burden of malaria leads to decreased long-term economic growth, and works against poverty eradication efforts and socioeconomic development of the country.

Background: Implementing initiatives to achieve the targets of MDG 5 requires sufficient financial resources that are mobilized and utilized in an equitable, efficient and sustainable manner. Informed decision making to this end requires the availability of reliable health financing information. This is accomplished by means of Reproductive Health (RH) sub-account, which captures and organizes expenditure on RH services in two-dimensional tables from financing sources to end users. The specific objectives of this study are: (i) to quantify total expenditure on reproductive health services; and (ii) to examine the flow of RH funds from sources to end users., Methods: The RH sub-account was part of the general National Health Accounts exercise covering the Financial Years 2007/08 and 2008/09. Primary data were collected from employers, medical aid schemes, donors and government ministries using questionnaire. Secondary data were obtained from various documents of the Namibian Government and the health financing database of the World Health Organization. Data were analyzed using a data screen designed in Microsoft Excel., Results: RH expenditure per woman of reproductive age was US$ 148 and US$ 126 in the 2007/08 and 2008/09 financial years respectively. This is by far higher than what is observed in most African countries. RH expenditure constituted more than 10-12% of the total expenditure on health. Out-of-pocket payment for RH was minimal (less than 4% of the RH spending in both years). Government is the key source of RH spending. Moreover, the public sector is the main financing agent with programmatic control of RH funds and also the main provider of services. Most of the RH expenditure is spent on services of curative care (both in- and out-patient). The proportion allocated for preventive and public health services was not more than 5% in the two financial years., Conclusion: Namibia's expenditure on reproductive health is remarkable by the standards of Africa and other middle-income countries. However, an increasing maternal mortality ratio does not bode well with the level of reproductive health expenditure. It is therefore important to critically examine the state of efficiency in the allocation and use of reproductive health expenditures in order to improve health outcomes.

Background: Out of 1.484 billion disability-adjusted life years lost globally in 2008, 369.1 million (25%) were lost in the WHO African Region. Despite the heavy disease burden, the majority of countries in the Region are not on track to achieve Millennium Development Goals (MDG) 4 (reducing child mortality), 5 (improving maternal health), and 6 (combating HIV/AIDS, malaria and other diseases). This article provides an overview of the state of public health, summarizes 2010-2015 WHO priorities, and explores the role that private sector could play to accelerate efforts towards health MDGs in the African Region., Discussion: Of the 752 total resolutions adopted by the WHO Regional Committee for Africa (RC) between years 1951 and 2010, 45 mention the role of the private sector. We argue that despite the rather limited role implied in RC resolutions, the private sector has a pivotal role in supporting the achievement of health MDGs, and articulating efforts with 2010-2015 priorities for WHO in the African Region: provision of normative and policy guidance as well as strengthening partnerships and harmonization; supporting the strengthening of health systems based on the Primary Health Care approach; putting the health of mothers and children first; accelerating actions on HIV/AIDS, malaria and tuberculosis; intensifying the prevention and control of communicable and noncommunicable diseases; and accelerating response to the determinants of health., Conclusion: The very high maternal and children mortality, very high burden of communicable and non-communicable diseases, health systems challenges, and inter-sectoral issues related to key determinants of health are too heavy for the public sector to address alone. Therefore, there is clear need for the private sector, given its breadth, scope and size, to play a more significant role in supporting governments, communities and partners to develop and implement national health policies and strategic plans; strengthen health systems capacities; and implement roadmaps for accelerating the attainment of health MDGs relating to maternal and child health, reducing disease burden, and promoting social determinants of health.In order for governments to further explore the potential benefits of the private sector towards improved performance of health systems, there is need for accurate evidence on the private sector capacity in areas of prevention, promotion, treatment and rehabilitation; dialogue and negotiation; clear definition of roles and responsibilities; and regulatory frameworks.

Background: Even though Africa has the highest disease burden compared with other regions, it has the lowest per capita spending on health. In 2007, 27 (51%) out the 53 countries spent less than US$50 per person on health. Almost 30% of the total health expenditure came from governments, 50% from private sources (of which 71% was from out-of-pocket payments by households) and 20% from donors. The purpose of this article is to reflect on the proceedings of the African Union Side Event on Health Financing in the African continent., Methods: Methods employed in the session included presentations, panel discussion and open public discussion with ministers of health and finance from the African continent., Discussion: The current unsatisfactory state of health financing was attributed to lack of clear vision and plan for health financing; lack of national health accounts and other evidence to guide development and implementation of national health financing policies and strategies; low investments in sectors that address social determinants of health; predominance of out-of-pocket spending; underdeveloped prepaid health financing mechanisms; large informal sectors vis-à-vis small formal sectors; and unpredictability and non-alignment of majority of donor funds with national health priorities.Countries need to develop and adopt a comprehensive national health policy and a costed strategic plan; a comprehensive evidence-based health financing strategy; allocate at least 15% of the national budget to health development; use GFATM and PEPFAR funds for health systems strengthening; strengthen intersectoral collaboration to address health determinants; advocate among donors to implement the Paris Declaration on Aid Effectiveness and its Accra Agenda for Action; ensure universal access to health services for pregnant women, lactating mothers and children aged under five years; strengthen financial management capacities; and develop prepaid health financing systems, especially health insurance to complement tax funding.In addition, countries need to institutionalize national health accounts; undertake feasibility studies of various health financing mechanisms; and document and share best practices in health financing., Conclusion: There was consensus that every country ought to have an evidence-based comprehensive health financing strategy with a road map for attaining universal health service coverage vision; and increase physical and financial access by pregnant women, lactating mothers and by children under five years to quality health services.

Background: In 2009 a total of 153,408 malaria deaths were reported in Africa. Eleven countries showed a reduction of more than 50% in either confirmed malaria cases or malaria admissions and deaths in recent years. However, many African countries are not on track to achieve the malaria component of the Millennium Development Goal (MDG) 6. The African Leaders Malaria Alliance (ALMA) working session at the 15th African Union Summit discussed the bottlenecks to achieving MDG 6 (specifically halting and beginning to reverse the incidence of malaria by 2015), success factors, and what countries needed to do to accelerate achievement of the MDG. The purpose of this article is to reflect on the proceedings of the ALMA working session., Methods: Working methods of the session included speeches and statements by invited speakers and high-level panel discussions., Discussion: The main bottlenecks identified related to the capacity of the health systems to deliver quality care and accessibility issues; need for strong, decentralized malaria-control programmes with linkages with other health and development sectors, the civil society and private sector entities; benefits of co-implementation of malaria control programmes with child survival or other public health interventions; systematic application of integrated promotive, preventive, diagnostic and case management interventions with full community participation; adapting approaches to local political, socio-cultural and administrative environments.The following prerequisites for success were identified: a clear vision and effective leadership of national malaria control programmes; high level political commitment to ensure adequate capacity in expertise, skill mix and number of managers, technicians and service providers; national ownership, intersectoral collaboration and accountability, as well as strong civil society and private sector involvement; functional epidemiological surveillance systems; and levering of African Union and regional economic communities to address the cross-border dimension of malaria control.It was agreed that countries needed to secure adequate domestic and external funding for sustained commitment to malaria elimination; strengthen national malaria control programmes in the context of broader health system strengthening; ensure free access to long-lasting insecticide treated nets and malaria diagnosis and treatment for vulnerable groups; strengthen human resource capacity at central, district and community levels; and establish strong logistics, information and surveillance systems., Conclusion: It is critically important for countries to have a clear vision and strategy for malaria elimination; effective leadership of national malaria control programmes; draw lessons from other African countries that have succeeded to dramatically reduce the burden of malaria; and sustain funding and ongoing interventions.

Background: Out of 358000 maternal deaths that occurred globally in 2008, 57.8% occurred in continental Africa. Africa had a maternal mortality ratio of 590 compared to 14 in developed regions, 68 in Latin America and Caribbean, and 190 in Asia. This article reflects on the discussions held during the Fifteenth Assembly of the Heads of State and Government of the African Union on the reasons why the maternal mortality ratio is so high in Africa and what can be done to reduce it., Methods: Methods employed included panel and open public discussions among the Heads of State and Government of the African Union. The article uses the WHO health systems strengthening framework, which consists of six pillars (information systems, leadership and governance, health workforce, financing, and medical products, vaccines and technologies, and health services) to describe the proceedings of the discussions., Discussion: The high maternal mortality ratios in countries were attributed to weak national health information systems; leadership and governance challenges related to poverty, health illiteracy, poor transport networks and communications infrastructure, risky cultural practices, armed conflicts and domestic violence, dearth of women empowerment; inadequate levels of skilled birth attendants; inadequate domestic and external funding; stock-outs of consumable inputs; and limited coverage of maternal and child health interventions.In order to accelerate progress towards MDGs 4 and 5, the Heads of State and Government recommended that countries should make maternal deaths notifiable and institutionalize maternal death audits; develop, fund and implement policies and strategies geared at improving maternal, newborn and child health; accelerate inter-sectoral action to address the broad health determinants; increase the number of skilled birth attendants; fulfil commitment to allocate at least 15% of the national budget to the health sector and allocate adequate resources to prevent stock-outs of essential medicines and reproductive health commodities; leverage health promotion approaches to raise national awareness; and ensure that there is a health centre within a radius of four kilometres equipped to provide good quality integrated maternal, newborn and child health services., Conclusions: There was consensus among the discussants that there was urgent need to speed up actions for strengthening health systems to improve coverage of maternal, newborn and child health services; and to address broad determinants of women, newborn and children's health for sustained improvements in health and other development goals.

Background: The fifth Millennium Development Goal (MDG5) aims at improving maternal health. Globally, the maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. During the same period, MMR in sub-Saharan Africa decreased from 870 to 640. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. In Namibia, there are significant inequities in births attended by skilled providers that favour those that are economically better off. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers., Methods: Namibia Demographic and Health Survey data of 2006-07 are analysed for the causes of inequities in skilled birth attendance using a decomposable health concentration index and the framework of the Commission on Social Determinants of Health., Results: About 80.3% of the deliveries were attended by skilled health providers. Skilled birth attendance in the richest quintile is about 70% more than that of the poorest quintile. The rate of skilled attendance among educated women is almost twice that of women with no education. Furthermore, women in urban areas access the services of trained birth attendant 30% more than those in rural areas. Use of skilled birth attendants is over 90% in Erongo, Hardap, Karas and Khomas Regions, while the lowest (about 60-70%) is seen in Kavango, Kunene and Ohangwena. The concentration curve and concentration index show statistically significant wealth-related inequalities in delivery by skilled providers that are to the advantage of women from economically better off households (C = 0.0979; P < 0.001).Delivery by skilled health provider by various maternal and household characteristics was 21 percentage points higher in urban than rural areas; 39 percentage points higher among those in richest wealth quintile than the poorest; 47 percentage points higher among mothers with higher level of education than those with no education; 5 percentage points higher among female headed households than those headed by men; 20 percentage points higher among people with health insurance cover than those without; and 31 percentage points higher in Karas region than Kavango region., Conclusion: Inequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel. This clearly implies that addressing inequalities in access to child delivery services should not be confined to the health system and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.

Background: The objectives of the study reported in this paper were to (i) estimate the technical efficiency of samples of community health centres (CHCs), community health posts (CHPs) and maternal and child health posts (MCHPs) in Kailahun and Kenema districts of Sierra Leone, (ii) estimate the output increases needed to make inefficient MCHPs, CHCs and CHPs efficient, and (iii) explore strategies for increasing technical efficiency of these institutions., Methods: This study applies the data envelopment analysis (DEA) approach to analyse technical efficiency of random samples of 36 MCHPs, 22 CHCs and 21 CHPs using input and output data for 2008., Results: The findings indicate that 77.8% of the MCHPs, 59.1% of the CHCs and 66.7% of the CHPs were variable returns to scale technically inefficient. The average variable returns to scale technical efficiency was 68.2% (SD = 27.2) among the MCHPs, 69.2% (SD = 33.2) among the CHCs and 59% (SD = 34.7) among the CHPs., Conclusion: This study reveals significant technical inefficiencies in the use of health system resources among peripheral health units in Kailahun and Kenema districts of Sierra Leone. There is need to strengthen national and district health information systems to routinely track the quantities and prices of resources injected into the health care systems and health service outcomes (indicators of coverage, quality and health status) to facilitate regular efficiency analyses.

Background: There is ample evidence in Asia and Latin America showing that past economic crises resulted in cuts in expenditures on health, lower utilization of health services, and deterioration of child and maternal nutrition and health outcomes. Evidence on the impact of past economic crises on health sector in Africa is lacking. The objectives of this article are to present the findings of a quick survey conducted among countries of the WHO African Region to monitor the effects of global financial crisis on funding for health development; and to discuss the way forward., Methods: This is a descriptive study. A questionnaire was prepared and sent by email to all the 46 Member States in the WHO African Region through the WHO Country Office for facilitation and follow up. The questionnaires were completed by directors of policy and planning in ministries of health. The data were entered and analyzed in Excel spreadsheet. The main limitations of this study were that authors did not ask whether other relevant sectors were consulted in the process of completing the survey questionnaire; and that the overall response rate was low., Results: The main findings were as follows: the response rate was 41.3% (19/46 countries); 36.8% (7/19) indicated they had been notified by the Ministry of Finance that the budget for health would be cut; 15.8% (3/19) had been notified by partners of their intention to cut health funding; 61.1% (11/18) indicated that the prices of medicines had increased recently; 83.3% (15/18) indicated that the prices of basic food stuffs had increased recently; 38.8% (7/18) indicated that their local currency had been devalued against the US dollar; 47.1% (8/17) affirmed that the levels of unemployment had increased since the onset of global financial crisis; and 64.7% (11/17) indicated that the ministry of health had taken some measures already, either in reaction to the global financing crisis, or in anticipation., Conclusion: A rapid assessment, like the one reported in this article, of the effects of the global financial crisis on a few variables, is important to alert the Ministry of Health on the looming danger of cuts in health funding from domestic and external sources. However, it is even more important for national governments to monitor the effects of the economic crisis and the policy responses on the social determinants of health, health inputs, health system outputs and health system outcomes, e.g. health.

Background: Governance and leadership in health development are critically important for the achievement of the health Millennium Development Goals (MDGs) and other national health goals. Those two factors might explain why many countries in Africa are not on track to attain the health MDGs by 2015. This paper debates the meaning of 'governance in health development', reviews briefly existing governance frameworks, proposes a modified framework on health development governance (HDG), and develops a HDG index., Discussion: We argue that unlike 'leadership in health development', 'governance in health development' is the sole prerogative of the Government through the Ministry of Health, which can choose to delegate (but not abrogate) some of the governance tasks. The general governance domains of the UNDP and the World Bank are very pertinent but not sufficient for assessment of health development governance. The WHO six domains of governance do not include effective external partnerships for health, equity in health development, efficiency in resource allocation and use, ethical practises in health research and service provision, and macroeconomic and political stability. The framework for assessing health systems governance developed by Siddiqi et al also does not include macroeconomic and political stability as a separate principle. The Siddiqi et al framework does not propose a way of scoring the various governance domains to facilitate aggregation, inter-country comparisons and health development governance tracking over time.This paper argues for a broader health development governance framework because other sectors that assure human rights to education, employment, food, housing, political participation, and security combined have greater impact on health development than the health systems. It also suggests some amendments to Siddigi et al's framework to make it more relevant to the broader concept of 'governance in health development' and to the WHO African Region context., Summary: A strong case for broader health development governance framework has been made. A health development governance index with 10 functions and 42 sub-functions has been proposed to facilitate inter-country comparisons. Potential sources of data for estimating HDGI have been suggested. The Governance indices for individual sub-functions can aid policy-makers to establish the sources of weak health governance and subsequently develop appropriate interventions for ameliorating the situation.

Background: Botswana national health policy states that the Ministry of Health shall from time to time review and revise its organization and management structures to respond to new developments and challenges in order to achieve and sustain a high level of efficiency in the provision of health care. Even though the government clearly views assuring efficiency in the health sector as one of its leadership and governance responsibilities, to date no study has been undertaken to measure the technical efficiency of hospitals which consume the majority of health sector resources. The specific objectives of this study were to quantify the technical and scale efficiency of hospitals in Botswana, and to evaluate changes in productivity over a three year period in order to analyze changes in efficiency and technology use., Methods: DEAP software was used to analyze technical efficiency along with the DEA-based Malmquist productivity index which was applied to a sample of 21 non-teaching hospitals in the Republic of Botswana over a period of three years (2006 to 2008)., Results: The analysis revealed that 16 (76.2 percent), 16 (76.2 percent) and 13 (61.9 percent) of the 21 hospitals were run inefficiently in 2006, 2007 and 2008, with average variable returns to scale (VRS) technical efficiency scores of 70.4 percent, 74.2 percent and 76.3 percent respectively. On average, Malmquist Total Factor Productivity (MTFP) decreased by 1.5 percent. Whilst hospital efficiency increased by 3.1 percent, technical change (innovation) regressed by 4.5 percent. Efficiency change was thus attributed to an improvement in pure efficiency of 4.2 percent and a decline in scale efficiency of 1 percent. The MTFP change was the highest in 2008 (MTFP = 1.008) and the lowest in 2007 (MTFP = 0.963)., Conclusions: The results indicate significant inefficiencies within the sample for the years under study. In 2008, taken together, the inefficient hospitals would have needed to increase the number of outpatient visits by 117627 (18 percent) and inpatient days by 49415 (13 percent) in order to reach full efficiency. Alternatively, inefficiencies could have been reduced by transferring 264 clinical staff and 39 beds to health clinics, health posts and mobile posts. The transfer of excess clinical staff to those facilities which are closest to the communities may also contribute to accelerating progress towards the Millennium Development Goals related to child and maternal health.Nine (57.1 percent) of the 21 hospitals experienced MTFP deterioration during the three years. We found the sources of inefficiencies to be either adverse change in pure efficiency, scale efficiency and/or technical efficiency.In line with the report Health financing: A strategy for the African Region, which was adopted by the Fifty-sixth WHO Regional Committee for Africa, it might be helpful for Botswana to consider institutionalizing efficiency monitoring of health facilities within health management information systems.

Background: In 2007, various countries around the world notified 178677 cases of cholera and 4033 cholera deaths to the World Health Organization (WHO). About 62% of those cases and 56.7% of deaths were reported from the WHO African Region alone. To date, no study has been undertaken in the Region to estimate the economic burden of cholera for use in advocacy for its prevention and control. The objective of this study was to estimate the direct and indirect cost of cholera in the WHO African Region., Methods: Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health-care system and the family in directly addressing cholera; and (b) the indirect costs, i.e. loss of productivity caused by cholera, which is borne by the individual, the family or the employer. The study was based on the number of cholera cases and deaths notified to the World Health Organization by countries of the WHO African Region., Results: The 125018 cases of cholera notified to WHO by countries of the African Region in 2005 resulted in a real total economic loss of US$39 million, US$ 53.2 million and US$64.2 million, assuming a regional life expectancies of 40, 53 and 73 years respectively. The 203,564 cases of cholera notified in 2006 led to a total economic loss US$91.9 million, US$128.1 million and US$156 million, assuming life expectancies of 40, 53 and 73 years respectively. The 110,837 cases of cholera notified in 2007 resulted in an economic loss of US$43.3 million, US$60 million and US$72.7 million, assuming life expectancies of 40, 53 and 73 years respectively., Conclusion: There is an urgent need for further research to determine the national-level economic burden of cholera, disaggregated by different productive and social sectors and occupations of patients and relatives, and national-level costs and effectiveness of alternative ways of scaling up population coverage of potable water and clean sanitation facilities.

Background: In 2000, the prevalence of diabetes among the 46 countries of the WHO African Region was estimated at 7.02 million people. Evidence from North America, Europe, Asia, Latin America and the Caribbean indicates that diabetes exerts a heavy health and economic burden on society. Unfortunately, there is a dearth of such evidence in the WHO African Region. The objective of this study was to estimate the economic burden associated with diabetes mellitus in the countries in the African Region., Methods: Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health systems and the families in directly addressing the problem; and (b) the indirect costs, i.e. the losses in productivity attributable to premature mortality, permanent disability and temporary disability caused by the disease. Prevalence estimates of diabetes for the year 2000 were used to calculate direct and indirect costs of diabetes mellitus. A discount rate of 3% was used to convert future earnings lost into their present values. The economic burden analysis was done for three groups of countries, i.e. 6 countries whose gross national income (GNI) per capita was greater than 8000 international dollars (i.e. in purchasing power parity), 6 countries with Int$2000-7999 and 33 countries with less than Int$2000. GNI for Zimbabwe was missing., Results: The 7.02 million cases of diabetes recorded by countries of the African Region in 2000 resulted in a total economic loss of Int$25.51 billion (PPP). Approximately 43.65%, 10.03% and 46.32% of that loss was incurred by groups 1, 2 and 3 countries, respectively. This translated into grand total economic loss of Int$11,431.6, Int$4,770.6 and Int$ 2,144.3 per diabetes case per year in the three groups respectively., Conclusion: In spite of data limitations, the estimates reported here show that diabetes imposes a substantial economic burden on countries of the WHO African Region. That heavy burden underscores the urgent need for increased investments in the prevention and management of diabetes.

Objectives: This paper proposes an analytical framework for assessing compliance of national health policies with WHO/AFRO guidelines., Data Sources: Data for this study was obtained from the national health policies of Botswana, Eritrea, Liberia, Namibia, Swaziland, Gambia, and Uganda., Study Selections: National health policies of seven of the 19 Anglophone countries of the WHO African region were selected for review using simple random sampling method. These include: Botswana, Eritrea, Liberia, Namibia, Swaziland, Gambia, and Uganda., Data Extraction: An analytical framework derived from WHO/AFRO guidelines for developing national health policies and plans was used in the review. It identifies components which are pertinent for appropriate national health policy formulation., Data Synthesis: It appears that aspects related to policy content are well addressed. In relation to the process, there is need for improving the mapping of stakeholders and specifying their roles and aspects of collaboration; and the implications for meeting broad service and impact targets., Conclusion: Development of health policies needs to focus on all aspects of the analytical framework with emphasis on improving the articulation for mapping out stakeholders and specifying their roles and aspects of collaboration; and the implications for meeting broad service and impact targets.