Hospital costs of central line-associated bloodstream infections and cost-effectiveness of closed vs. open infusion containers. The case of Intensive Care Units in Italy

Background

Little is known about the cost recovery of primary health care facilities in Bangladesh. This study estimated the cost recovery of a primary health care facility run by Building Resources Across Community (BRAC), a large NGO in Bangladesh, for the period of July 2004 - June 2005. This health facility is one of the seven upgraded BRAC facilities providing emergency obstetric care and is typical of the government and private primary health care facilities in Bangladesh. Given the current maternal and child mortality in Bangladesh and the challenges to addressing health-related Millennium Development Goal (MDG) targets the financial sustainability of such facilities is crucial.

Methods

The study was designed as a case study covering a single facility. The methodology was based on the 'ingredient approach' using the allocation techniques by inpatient and outpatient services. Cost recovery of the facility was estimated from the provider's perspective. The value of capital items was annualized using 5% discount rate and its market price of 2004 (replacement value). Sensitivity analysis was done using 3% discount rate.

Results

The cost recovery ratio of the BRAC primary care facility was 59%, and if excluding all capital costs, it increased to 72%. Of the total costs, 32% was for personnel while drugs absorbed 18%. Capital items were17% of total costs while operational cost absorbed 12%. Three-quarters of the total cost was variable costs. Inpatient services contributed 74% of total revenue in exchange of 10% of total utilization. An average cost per patient was US$ 10 while it was US$ 67 for inpatient and US$ 4 for outpatient.

Conclusion

The cost recovery of this NGO primary care facility is important for increasing its financial sustainability and decreasing donor dependency, and achieving universal health coverage in a developing country setting. However, for improving the cost recovery of the health facility, it needs to increase utilization, efficient planning, resource allocation and their optimum use. It also requires controlling variable costs and preventing any wastage of resources.     

Use of a Balanced Scorecard in strengthening health systems in developing countries: an analysis based on nationally representative Bangladesh Health Facility Survey

This paper illustrates the importance of collecting facility‐based data through regular surveys to supplement the administrative data, especially for developing countries of the world. In Bangladesh, measures based on facility survey indicate that only 70% of very basic medical instruments and 35% of essential drugs were available in health facilities. Less than 2% of officially designated obstetric care facilities actually had required drugs, injections and personnel on‐site. Majority of (80%) referral hospitals at the district level were not ready to provide comprehensive emergency obstetric care. Even though the Management Information System reports availability of diagnostic machines in all district‐level and sub‐district‐level facilities, it fails to indicate that 50% of these machines are not functional. In terms of human resources, both physicians and nurses are in short supply at all levels of the healthcare system. The physician–nurse ratio also remains lower than the desirable level of 3.0. Overall job satisfaction index was less than 50 for physicians and 66 for nurses. Patient satisfaction score, however, was high (86) despite the fact that process indicators of service quality were poor. Facility surveys can help strengthen not only the management decision‐making process but also the quality of administrative data. Copyright © 2012 John Wiley & Sons, Ltd.     

Health care cost-recovery simulations from parametric estimates: methodology and results for Ogun State, Nigeria

Cost recovery in the health care sector in developing countries can be a powerful tool for achieving efficiency and equity goals, and for mobilizing financial resources for the improvement of quality. However, there is only fragmentary empirical evidence on the revenue, quality and cost effects of cost-recovery policies in the health care sector. Using parameter estimates from cost and demand functions that were derived from data from a facility and household interview survey in Ogun State. Nigeria, this article simulates various cost-recovery scenarios for the public sector. The empirical results of the simulations show that, under certain realistic scenarios, cost recovery will generate additional revenue and improve quality. Equity would be enhanced by spending some of the additional net cost-recovery revenue on health care for the poor.     

对社区卫生服务补偿机制的思考

通过对华阳地段医院１９９６～１９９８年医院收支、财政拨款与防保经费收支情况分析,阐述了医院补偿机制的重要性和必要性。探讨医院补偿途径,提出新形势下拓宽卫生筹资渠道,对于基层医院卫生服务功能定位,促进医疗改革顺利实施具有重要意义。     

Stakeholders analysis of merging social health insurance funds in Iran: what kind of interests they may gain or lose?

Iran passed a Law in 2010 to merge all existing health insurance funds physically together. This stakeholder analysis aimed at revealing that what benefits the stakeholders might lose or gain as a result of merging health insurance schemes in Iran, which make them to oppose or support it. This was a qualitative study conducted in 2014. Sixty semi‐structured face‐to‐face interviews were conducted. Purposive and snowball samplings with maximum heterogeneity samples were used for selecting interviewees. Government is not willing to undertake more financial commitment. Existing health insurance schemes like Social Security Organization and minor well‐resourced health insurance funds and also worker unions are unwilling to lose their financial and organizational autonomy, to share their benefits with other less privileged groups, or face likely financial challenges in running their health facilities like hospitals. Top managers and workforces are worried to lose their job, salary, or organizational positions. Ministry of Cooperation, Labour, and Social Welfare does not want to lose its control on health insurance schemes. Ministry of Health and Medical Education and Iran Health Insurance Organization are among actors that support the insurance funds merging policy. Successful implementing of consolidation requires taking into account the interests of different stakeholders.     

Local governance and community financing of primary care: evidence from Nepal

Improved community participation in the financing of primary health care (PHC) is important for sustaining quality and availability of care in developing countries. This study asks whether the social status of members on a local support committee is associated with community contributions to PHC. A survey of PHC financing was conducted at 42 health facilities in two rural districts of Nepal (Jumla and Nawal Parasi). Complete data were available for 37 clinics. At each health facility, a trained interviewer collected information from the clinic administrator about the caste characteristics of the Village Development Committees (VDC) and the financial contributions made by VDCs towards the operation of the health facilities. Bivariate and multivariate logistic regression assessed the likelihood of financial contribution as it related to the caste and gender composition of the VDC as well as other characteristics of the VDC and the facility. VDCs with a majority of committee members in castes other than the highest two had higher odds of contributing to the health centre. We conclude that local development committees with a greater representation of middle and low caste members are more likely to contribute financially to the local health facility. Future research must determine the factors that lead some villages to include low caste villagers in local government.     

Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan

BACKGROUND User fees for primary care tend to suppress utilization, and many countries are experimenting with fee removal. Studies show that additional inputs are needed after removing fees, although well-documented experiences are lacking. This study presents data on the effects of fee removal on facility quality and utilization in Afghanistan, based on a pilot experiment and subsequent nationwide ban on fees. METHODS Data on utilization and observed structural and perceived overall quality of health care were compared from before-and-after facility assessments, patient exit interviews and catchment area household surveys from eight facilities where fees were removed and 14 facilities where fee levels remained constant, as part of a larger health financing pilot study from 2005 to 2007. After a national user fee ban was instituted in 2008, health facility administrative data were analysed to assess subsequent changes in utilization and quality. RESULTS The pilot study analysis indicated that observed and perceived quality increased across facilities but did not differ by fee removal status. Difference-in-difference analysis showed that utilization at facilities previously charging both service and drug fees increased by 400% more after fee removal, prompting additional inputs from service providers, compared with facilities that previously only charged service fees or had no change in fees (P = 0.001). Following the national fee ban, visits for curative care increased significantly (P < 0.001), but institutional deliveries did not. Services typically free before the ban-immunization and antenatal care-had immediate increases in utilization but these were not sustained. CONCLUSION Both pilot and nationwide data indicated that curative care utilization increased following fee removal, without differential changes in quality. Concerns raised by non-governmental organizations, health workers and community leaders over the effects of lost revenue and increased utilization require continued effort to raise revenues, monitor health worker and patient perceptions, and carefully manage health facility performance.     

卫生筹资与就医、处方行为研究

本文通过卫生筹资方式的分析，提出了进行卫生筹资与就医、处方行为研究的理论模型，研究指标与资料收集方法。并在介绍国内外研究结果以后提出了一些进行卫生筹资改革的建议。我们发现卫生筹资方式与支付机制对病人与医生的行为以及药物使用都有影响。相对于自费病人来说，保险病人有更多的机会得到新药与贵药、住院治疗与向高层次医院转诊，也消耗更多的卫生资源。以按服务收费为基础的保险可增加临床服务与药品消费，并导致卫生费用快速增长，医生可能根据病人的保险情况与支付能力改变处方与治疗方案，并且认为与服务和处方挂钩的奖金制度有可能刺激过多用药行为。建议有关决策部门在出台有关卫生筹资与支付方式政策时，要考虑医生与病人的行为变化对药物及其它服务使用的影响，并同时要有一套规范医生与病人行为的措施，减少资源浪费与使得新政策健康发展、建议有关部门进行合理用药研究，进一步达到降低卫生费用与提高质量的改革目的。     

海南省政府卫生项目支出与基本支出的现状与对策研究

目的:研究海南省政府卫生投入资金流向分配,项目资金分配占比是否符合当年各区域实时所需,分析评价政府卫生财政资金投入现状,为政府提供基于数据分析和实时分析的卫生财政投入策略。方法:根据政府卫生投入监测系统数据对海南省2017年政府卫生投入进行分析。结果:2017年卫生投入总费用为330929.59万元,项目支出多来源于中央专项资金,卫生行政单位支出在财政性卫生支出中占据较高比例,中央专项资金分配到位所需时间较长。结论:海南省政府在卫生投入项目支出里主要依赖于中央财政的分配,卫生费用主要用于卫生行政机构,应优化转移支付制度,推进政府机构改革,完善资金运行模式,提高资源效率配置。     

Reducing the cost of health care capital

Although one may ask four financial experts their opinion on the future of the hospital capital market and receive five answers, the blatant need for financial strategic planning is evident. Clearly, the hospital or system with sound financial management will be better positioned to gain and/or maintain an edge in the competitive environment of the health care sector. The trends of the future include hospitals attempting to: Maximize the efficiency of invested capital. Use the expertise of Board members. Use alternative capital sources. Maximize rate of return on investments. Increase productivity. Adjust to changes in reimbursements. Restructure to use optimal financing for capital needs, i.e., using short-term to build up debt capacity if long-term financing is needed in the future. Take advantage of arbitrage (obtain capital and reinvest it until the funds are needed). Delay actual underwriting until funds are to be used. Better management of accounts receivable and accounts payable to avoid short-term financing for cash flow shortfalls. Use for-profit subsidiaries to obtain venture capital by issuing stock. Use product line management. Use leasing to obtain balance sheet advantages. These trends indicate a need for hospital executives to possess a thorough understanding of the capital formation process. In essence, the bottom line is that the short-term viability and long-term survival of a health care organization will greatly depend on the financial expertise of its decision-makers.     

Health care rationing: its effects on cardiologists in the United States and Britain

Cardiologists practicing under contrasting types of health care rationing in the United States and Britain were found to differ significantly in the occupational stresses they experience, according to this exploratory study. In-depth interviews revealed that the 24 American physicians complained most about increasing limits to their autonomy resulting from the intrusion of government, insurance companies and managed care agencies. Twenty-one British cardiologists indicated greater concern about workloads and the lack of resources in the National Health Service. The stresses are associated with the different types of health care rationing in the two countries. In the United States, where explicit rationing exists, external controls are placed on length of hospital stays, tests and procedures, physicians' fees and the use of drugs. In Britain, implicit rationing is imposed by limiting overall funding of health care, leaving physicians free to make clinical decisions. However, the ethic of care for all and the limited funding create waiting lists and a lack of facilities.     

Decentralisation and health services delivery in Tanzania: Analysis of decision space in planning,allocation, and use of financial resources

While decentralisation of health systems has been on the policy agenda in low‐income and middle‐income countries since the 1970s, many studies have focused on understanding who has more decision‐making powers but less attention is paid to understand what those powers encompass. Using the decision space approach, this study aimed to understand the amount of decision‐making space transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania. The findings of this study indicated that the decentralisation process in Tanzania has provided authorities with a range of decision‐making space. In the areas of priority setting and planning, district health authorities had moderate decision space. However, in the financial resource allocation and expenditure of funds from the central government, the districts had narrow decision‐making space. The districts, nevertheless, had wider decision‐making space in mobilising and using locally generated financial resources. However, the ability of the districts to allocate and use locally generated resources was constrained by bureaucratic procedures of the central government. The study concludes that decentralisation by devolution which is being promoted in the policy documents in Tanzania is yet to be realised at the district and local levels. The study recommends that the central government should provide more space to the decentralised district health systems to incorporate locally defined priorities in the district health plans.     

Health planners and local public finance--the case for revenue sharing

Little attention has been paid by health planners or researchers to questions of local public finance. However, a review of the literature concerning general revenue sharing (GRS) funds indicated that about $400 million per year from this source is spent on health services and resources. GRS funds, about $6.4 billion per year, are distributed to more than 39,000 State, county, and city governments. The 1976 amendments to the General Revenue Sharing Act eliminated restrictions on the use of the funds, and they can be employed as matching funds for other Federal monies. An exploratory study of the use of GRS funds for health purposes was conducted in several localities, with particular attention to the health systems agencies. Its results confirmed that there are wide variations among localities in the use of revenue-sharing funds to support health services. Also, not only did the health systems agencies' officials have little impact on the allocation of revenue sharing funds, but only in one locale had an HSA official taken a direct role in the budgetary process. Health planners, who were interviewed during the study, described what they considered their agencies' proper role in local budgetary matters.     

A framework for assessing the performance of health systems

Health systems vary widely in performance, and countries with similar levels of income, education and health expenditure differ in their ability to attain key health goals. This paper proposes a framework to advance the understanding of health system performance. A first step is to define the boundaries of the health system, based on the concept of health action. Health action is defined as any set of activities whose primary intent is to improve or maintain health. Within these boundaries, the concept of performance is centred around three fundamental goals: improving health, enhancing responsiveness to the expectations of the population, and assuring fairness of financial contribution. Improving health means both increasing the average health status and reducing health inequalities. Responsiveness includes two major components: (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). Fairness of financial contribution means that every household pays a fair share of the total health bill for a country (which may mean that very poor households pay nothing at all). This implies that everyone is protected from financial risks due to health care. The measurement of performance relates goal attainment to the resources available. Variation in performance is a function of the way in which the health system organizes four key functions: stewardship (a broader concept than regulation); financing (including revenue collection, fund pooling and purchasing); service provision (for personal and non-personal health services); and resource generation (including personnel, facilities and knowledge). By investigating these four functions and how they combine, it is possible not only to understand the proximate determinants of health system performance, but also to contemplate major policy challenges.     

Medical e-commerce for regional Australia

The residents of rural and regional Australia have less access to health care services than in capital cities. There is a reluctance of General Practitioners to practice in the country. New information technology and government initiatives are now addressing this problem. High bandwidth videoconferencing is now being routinely used to provide psychiatric consultations to areas without this service. But this (like many other implementations of telecommunication technologies to health) has resulted in loss of revenue to regional Australia while benefiting capital cities. Thus, the current implementation of telecommunication technology to health has resulted in loss of revenue of the regions while increasing the bias towards the cities. Further, the system is not economically viable and requires the Government to inject funds for the smooth operation of the system. This paper proposes the use of telecommunication technology for enabling the communities of regional Australia to access health facilities via physical and virtual clinics. The proposed technique is self supporting and is based in the country with the intent to prevent the drain of resources from regional Australia. The technique attempts to eradicate the problem at the root level by providing a business opportunity that is based in and to cater for the needs of the remote communities. The proposed system would provide health services by physical and virtual clinics and while serving the communities would be profit centres- and thus attracting doctors and other resources to the remote communities.     

Networks strengthen ties, status of rural hospitals

Rural hospitals are a integral part of the health care system in this country. But a lack of funds and a shrinking patient-base are leaving many of them without the resources to provide state-of-the-art care in their communities. In the following article, the authors discuss a network model that brings urban hospitals to the financial and service aid of rural facilities.     

A Comparison of Financial Performance, Organizational Characteristics and Management Strategy Among Rural and Urban Nursing Facilities

Despite efforts to deinstitutionalize long-term care, it is estimated that 43 percent of the elderly will use a nursing facility at some point. Whether sufficient nursing facility services will be available to rural elderly is debatable due to cutbacks in governmental expenditures and recent financial losses among nursing facilities. This paper explores the challenges confronting rural nursing facilities in maintaining their viability and strategies that might be considered to improve their longevity. A comparative analysis of 18 urban and 34 rural nursing facilities in New Mexico is used in identifying promising strategic adaptations available to rural facilities. Among other considerations, rural facilities should strive to enhance revenue streams, implement strict cost control measures, emphasize broader promotional tactics, and diversify services commensurate with the constraints of the communities and populations served.     

Costs and revenue of health care in a rural Zimbabwean district

The District Health Executive of Tsholotsho district in south-west Zimbabwe conducted a health care cost study for financial year 1997-98. The study's main purpose was to generate data on the cost of health care of a relatively high standard, in a context of decentralization of health services and increasing importance of local cost-recovery arrangements. The methodology was based on a combination of step-down cost accounting and detailed observation of resource use at the point of service. The study is original in that it presents cost data for almost all of the health care services provided at district level. The total annualized cost of the district public health services in Tsholotsho amounted to US$10 per capita, which is similar to the World Bank's Better Health in Africa study (1994) but higher than in comparable studies in other countries of the region. This can be explained by the higher standards of care and of living in Zimbabwe at the time of the study. About 60% of the costs were for the district hospital, while the different first-line health care facilities (health centres and rural hospitals together) absorbed 40%. Some 54% of total costs for the district were for salaries, 20% for drugs, 11% for equipment and buildings (including depreciation) and 15% for other costs. The study also looked into the revenue available at district level: the main source of revenue (85%) was from the Ministry of Health. The potential for cost recovery was hardly exploited and revenue from user fees was negligible. The study results further question the efficiency and relevance of maintaining rural hospitals at the current level of capacity, confirm the soundness of a two-tiered district health system based on a rational referral system, and make a clear case for the management of the different elements of the budget at the decentralized district level. The study shows that it is possible to deliver district health care of a reasonable quality at a cost that is by no means exorbitant, albeit unfortunately not yet within reach of many sub-Saharan African countries today.