Kara Hanson

London School of Hygiene and Tropical Medicine, Londinium, England, United Kingdom

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Publications (134)612.71 Total impact

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    ABSTRACT: The private for-profit sector is an important source of treatment for malaria. However, private patients face high prices for the recommended treatment for uncomplicated malaria, artemisinin combination therapies (ACTs), which makes them more likely to receive cheaper, less effective non-artemisinin therapies (nATs). This study seeks to better understand consumer antimalarial prices by documenting and exploring the pricing behaviour of retailers and wholesalers. Using data collected in 2009-10, we present survey estimates of antimalarial retail prices, and wholesale- and retail-level price mark-ups from six countries (Benin, Cambodia, the Democratic Republic of Congo, Nigeria, Uganda and Zambia), along with qualitative findings on factors affecting pricing decisions. Retail prices were lowest for nATs, followed by ACTs and artemisinin monotherapies (AMTs). Retailers applied the highest percentage mark-ups on nATs (range: 40% in Nigeria to 100% in Cambodia and Zambia), whereas mark-ups on ACTs (range: 22% in Nigeria to 71% in Zambia) and AMTs (range: 22% in Nigeria to 50% in Uganda) were similar in magnitude, but lower than those applied to nATs. Wholesale mark-ups were generally lower than those at retail level, and were similar across antimalarial categories in most countries. When setting prices wholesalers and retailers commonly considered supplier prices, prevailing market prices, product availability, product characteristics and the costs related to transporting goods, staff salaries and maintaining a property. Price discounts were regularly used to encourage sales and were sometimes used by wholesalers to reward long-term customers. Pricing constraints existed only in Benin where wholesaler and retailer mark-ups are regulated; however, unlicensed drug vendors based in open-air markets did not adhere to the pricing regime. These findings indicate that mark-ups on antimalarials are reasonable. Therefore, improving ACT affordability would be most readily achieved by interventions that reduce commodity prices for retailers, such as ACT subsidies, pooled purchasing mechanisms and cost-effective strategies to increase the distribution coverage area of wholesalers. © The Author 2015; all rights reserved. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
    Health Policy and Planning 05/2015; DOI:10.1093/heapol/czv031 · 3.00 Impact Factor
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    ABSTRACT: In contexts where health services are mostly publicly provided and access is still limited, health financing systems require some mechanism for distributing financial resources across geographic areas according to population need. Equity in public health expenditure has been evaluated either by comparing allocations across spending units to equitable shares established using resource allocation formulae, or by using benefit incidence analysis to look at the distribution of expenditure across individual service users. In the latter case, the distribution across individuals has typically not been linked to the mechanisms that determine the allocation across geographic areas, and to the utilization of specific services by individuals.
    Social Science & Medicine 04/2015; 130. DOI:10.1016/j.socscimed.2015.02.012 · 2.56 Impact Factor
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    PLoS ONE 04/2015; 10(4):e0125072. DOI:10.1371/journal.pone.0125072 · 3.53 Impact Factor
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    ABSTRACT: In 2012, WHO changed its recommendation for intermittent preventive treatment of malaria during pregnancy (IPTp) from two doses to monthly doses of sulfadoxine-pyrimethamine during the second and third trimesters, but noted the importance of a cost-effectiveness analysis to lend support to the decision of policy makers. We therefore estimated the incremental cost-effectiveness of IPTp with three or more (IPTp-SP3+) versus two doses of sulfadoxine-pyrimethamine (IPTp-SP2). For this analysis, we used data from a 2013 meta-analysis of seven studies in sub-Saharan Africa. We developed a decision tree model with a lifetime horizon. We analysed the base case from a societal perspective. We did deterministic and probabilistic sensitivity analyses with appropriate parameter ranges and distributions for settings with low, moderate, and high background risk of low birthweight, and did a separate analysis for HIV-negative women. Parameters in the model were obtained for all countries included in the original meta-analysis. We did simulations in hypothetical cohorts of 1000 pregnant women receiving either IPTp-SP3+ or IPTp-SP2. We calculated disability-adjusted life-years (DALYs) for low birthweight, severe to moderate anaemia, and clinical malaria. We calculated cost estimates from data obtained in observational studies, exit surveys, and from public procurement databases. We give financial and economic costs in constant 2012 US$. The main outcome measure was the incremental cost per DALY averted. The delivery of IPTp-SP3+ to 1000 pregnant women averted 113·4 DALYs at an incremental cost of $825·67 producing an incremental cost-effectiveness ratio (ICER) of $7·28 per DALY averted. The results remained robust in the deterministic sensitivity analysis. In the probabilistic sensitivity analyses, the ICER was $7·7 per DALY averted for moderate risk of low birthweight, $19·4 per DALY averted for low risk, and $4·0 per DALY averted for high risk. The ICER for HIV-negative women was $6·2 per DALY averted. Our findings lend strong support to the WHO guidelines that recommend a monthly dose of IPTp-SP from the second trimester onwards. Malaria in Pregnancy Consortium and the Bill & Melinda Gates Foundation. Copyright © 2015 Fernandes et al. Open Access article distributed under the terms of CC BY-NC-SA. Published by .. All rights reserved.
    The Lancet Global Health 03/2015; 3(3):e143-53. DOI:10.1016/S2214-109X(14)70385-7
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    ABSTRACT: To describe the state of the public and private malaria diagnostics market shortly after WHO updated its guidelines for testing all suspected malaria cases prior to treatment. 10 nationally representative cross-sectional cluster surveys were conducted in 2011 among public and private health facilities, community health workers, and retail outlets (pharmacies and drug shops) in 9 countries (Tanzania-mainland and Zanzibar surveyed separately). Eligible outlets had antimalarials in stock on the day of interview or had stocked antimalarials in the past three months. 3,439 RDT products from 39 manufacturers were audited among 12,197 outlets interviewed. Availability was typically highest in public health facilities, though availability in these facilities varied greatly across countries, from 15% in Nigeria to >90% in Madagascar and Cambodia. Private for-profit sector availability was 46% in Cambodia, 20% in Zambia, but low in other countries. Median retail prices for RDTs in the private for-profit sector ranged from $0.00 in Madagascar to $3.13 in Zambia. The reported number of RDTs used in the 7 days before the survey in public health facilities ranged from 3 (Benin) to 50 (Zambia). 18 months after WHO updated its case management guidelines, RDT availability remained poor in the private sector in sub-Saharan Africa. Given the ongoing importance of the private sector as a source of fever treatment, the goal of universal diagnosis will not be achievable under current circumstances. These results constitute national baselines against which progress in scaling-up diagnostic tests can be assessed. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    Tropical Medicine & International Health 02/2015; 20(6). DOI:10.1111/tmi.12491 · 2.30 Impact Factor
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    ABSTRACT: This article examines why and how a national health insurance (NHI) proposal targeting universal health coverage (UHC) in Nigeria developed over time. The study involved document reviews, in-depth interviews, a further review of preliminary analysis by relevant actors and use of a stakeholder analysis approach. The need for strategies to improve healthcare funding during the economic recession of the 1980s stimulated the proposal. The inclusion of Health Maintenance Organizations (HMOs) as financing organizations for national health insurance at the expense of sub-national (state) government mechanisms increased credibility of policy implementation but resulted in loss of support from states. The most successful period of the policy process occurred when a new minister of health (strongly supported by the president that displayed interest in UHC) provided leadership through the Federal Ministry of Health (FMOH), and effectively managed stakeholders’ interests and galvanized their support to advance the
    Health Policy and Planning 10/2014; DOI:10.1093/heapol/czu116 · 3.00 Impact Factor
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    ABSTRACT: Artemisinin combination therapy (ACT) has been the first-line treatment for uncomplicated malaria in Cameroon since 2004 and Nigeria since 2005, though many febrile patients receive less effective antimalarials. Patients often rely on providers to select treatment, and interventions are needed to improve providers' practice and encourage them to adhere to clinical guidelines.
    Health Policy and Planning 10/2014; DOI:10.1093/heapol/czu118 · 3.00 Impact Factor
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    ABSTRACT: Objective There have been longstanding concerns over Malawian doctors migrating to high-income countries. Early career is a particularly vulnerable period. After significant policy changes, we examined the retention of recent medical graduates within Malawi and the public sector.Methods We obtained data on graduates between 2006 and 2012 from the University of Malawi College of Medicine and Malawi Ministry of Health. We utilised the alumni network to triangulate official data and contacted graduates directly for missing or uncertain data. Odds ratios and chi-squared tests were employed to investigate relationships by graduation year and gender.ResultsWe traced 256 graduates, with complete information for more than 90%. Nearly 80% of registered doctors were in Malawi (141/178, 79.2%), although the odds of emigration doubled with each year after graduation (odds ratio = 1.98, 95% CI = 1.54–2.56, P < 0.0001). Of the 37 graduates outside Malawi (14.5%), 23 (62.2%) were training in South Africa under a College of Medicine sandwich programme. More than 80% of graduates were working in the public sector (185/218, 82.6%), with the odds declining by 27% for each year after graduation (odds ratio = 0.73, 95% CI = 0.61–0.86, P < 0.0001).Conclusions While most doctors remain in Malawi and the public sector during their early careers, the odds of leaving both increase with time. The majority of graduates outside Malawi are training in South Africa under visa restrictions, reflecting the positive impact of postgraduate training in Malawi. Concerns over attrition from the public sector are valid and required further exploratory work.
    Tropical Medicine & International Health 10/2014; DOI:10.1111/tmi.12408 · 2.30 Impact Factor
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    ABSTRACT: Improving access to quality-assured artemisinin combination therapies (ACTs) is an important component of malaria control in low- and middle-income countries. In 2010 the Global Fund to Fight AIDS, Tuberculosis, and Malaria launched the Affordable Medicines Facility-malaria (AMFm) program in seven African countries. The goal of the program was to decrease malaria morbidity and delay drug resistance by increasing the use of ACTs, primarily through subsidies intended to reduce costs. We collected data on price and retail markups on antimalarial medicines from 19,625 private for-profit retail outlets before and 6-15 months after the program's implementation. We found that in six of the AMFm pilot programs, prices for quality-assured ACTs decreased by US$1.28-$4.34, and absolute retail markups on these therapies decreased by US$0.31-$1.03. Prices and markups on other classes of antimalarials also changed during the evaluation period, but not to the same extent. In all but two of the pilot programs, we found evidence that prices could fall further without suppliers' losing money. Thus, concerns may be warranted that wholesalers and retailers are capturing subsidies instead of passing them on to consumers. These findings demonstrate that supranational subsidies can dramatically reduce retail prices of health commodities and that recommended retail prices communicated to a wide audience may be an effective mechanism for controlling the market power of private-sector antimalarial retailers and wholesalers.
    Health Affairs 09/2014; 33(9):1576-85. DOI:10.1377/hlthaff.2014.0104 · 4.32 Impact Factor
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    ABSTRACT: Discrete choice experiments have become a popular study design to study the labour market preferences of health workers. Discrete choice experiments in health, however, have been criticised for lagging behind best practice and there are specific methodological considerations for those focused on job choices. We performed a systematic review of the application of discrete choice experiments to inform health workforce policy.
    BMC Health Services Research 09/2014; 14(1):367. DOI:10.1186/1472-6963-14-367 · 1.66 Impact Factor
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    ABSTRACT: Randomized controlled trials (RCTs) are increasingly popular for assessing development programmes. This study investigates the validity of extrapolating RCT results to large-scale programmes, using the example of the national bed net subsidy programme in Tanzania that later added a free distribution campaign. Although the RCTs suggest steady sales of nets throughout, an interrupted time series model reveals a 34 per cent monthly decline immediately after the campaign compared to ‘normal’ sales. After 6 months, the total unsold nets reached 45 per cent of normal sales, or 347 000 nets nationwide. We hypothesize that these differences in results arise from various scale and spillover effects. Copyright © 2013 John Wiley & Sons, Ltd.
    Journal of International Development 08/2014; 26(6). DOI:10.1002/jid.2941 · 0.88 Impact Factor
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    ABSTRACT: This review aims to identify, assess and analyse the evidence on equity in the distribution of public health sector expenditure in low- and middle-income countries. Four bibliographic databases and five websites were searched to identify quantitative studies examining equity in the distribution of public health funding in individual countries or groups of countries. Two different types of studies were identified: benefit incidence analysis (BIA) and resource allocation comparison (RAC) studies. Quality appraisal and data synthesis were tailored to each study type to reflect differences in the methods used and in the information provided. We identified 39 studies focusing on African, Asian and Latin American countries. Of these, 31 were BIA studies that described the distribution, typically across socio-economic status, of individual monetary benefit derived from service utilization. The remaining eight were RAC studies that compared the actual expenditure across geographic areas to an ideal need-based distribution. Overall, the quality of the evidence from both types of study was relatively weak. Looking across studies, the evidence confirms that resource allocation formulae can enhance equity in resource allocation across geographic areas and that the poor benefits proportionally more from primary health care than from hospital expenditure. The lack of information on the distribution of benefit from utilization in RAC studies and on the countries' approaches to resource allocation in BIA studies prevents further policy analysis. Additional research that relates the type of resource allocation mechanism to service provision and to the benefit distribution is required for a better understanding of equity-enhancing resource allocation policies.
    Health Policy and Planning 05/2014; 30(4). DOI:10.1093/heapol/czu034 · 3.00 Impact Factor
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    ABSTRACT: The Affordable Medicines Facility - malaria (AMFm) is primarily an artemisinin combination therapy (ACT) subsidy, aimed at increasing availability, affordability, market share and use of quality-assured ACTs (QAACTs). Mainland Tanzania was one of eight national scale programmes where AMFm was introduced in 2010. Here we present findings from outlet and household surveys before and after AMFm implementation to evaluate its impact from both the supply and demand side. Outlet surveys were conducted in 49 randomly selected wards throughout mainland Tanzania in 2010 and 2011, and data on outlet characteristics and stocking patterns were collected from outlets stocking antimalarials. Household surveys were conducted in 240 randomly selected enumeration areas in three regions in 2010 and 2012. Questions about treatment seeking for fever and drugs obtained were asked of individuals reporting fever in the previous two weeks. The availability of QAACTs increased from 25.5% to 69.5% among all outlet types, with the greatest increase among pharmacies and drug stores, together termed specialised drug sellers (SDSs), where the median QAACT price fell from $5.63 to $0.94. The market share of QAACTs increased from 26.2% to 42.2%, again with the greatest increase in SDSs. Household survey results showed a shift in treatment seeking away from the public sector towards SDSs. Overall, there was no change in the proportion of people with fever obtaining an antimalarial or ACT from baseline to endline. However, when broken down by treatment source, ACT use increased significantly among clients visiting SDSs. Unchanged ACT use overall, despite increases in QAACT availability, affordability and market share in the private sector, reflected a shift in treatment seeking towards private providers. The reasons for this shift are unclear, but likely reflect both persistent stockouts in public facilities, and the increased availability of subsidised ACTs in the private sector.
    PLoS ONE 05/2014; 9(5):e95607. DOI:10.1371/journal.pone.0095607 · 3.53 Impact Factor
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    ABSTRACT: Private for-profit outlets are important treatment sources for malaria in most endemic countries. However, these outlets constitute only the last link in a chain of businesses that includes manufacturers, importers and wholesalers, all of which influence the availability, price and quality of antimalarials patients can access. We present evidence on the composition, characteristics and operation of these distribution chains and of the businesses that comprise them in six endemic countries (Benin, Cambodia, Democratic Republic of Congo, Nigeria, Uganda and Zambia). We conducted nationally representative surveys of antimalarial wholesalers during 2009-2010 using an innovative sampling approach that captured registered and unregistered distribution channels, complemented by in-depth interviews with a range of stakeholders. Antimalarial distribution chains were pyramidal in shape, with antimalarials passing through a maximum of 4-6 steps between manufacturer and retailer; however, most likely pass through 2-3 steps. Less efficacious non-artemisinin therapies (e.g. chloroquine) dominated weekly sales volumes among African wholesalers, while volumes for more efficacious artemisinin-based combination therapies (ACTs) were many times smaller. ACT sales predominated only in Cambodia. In all countries, consumer demand was the principal consideration when selecting products to stock. Selling prices and reputation were key considerations regarding supplier choice. Business practices varied across countries, with large differences in the proportions of wholesalers offering credit and delivery services to customers, and the types of distribution models adopted by businesses. Regulatory compliance also varied across countries, particularly with respect to licensing. The proportion of wholesalers possessing any up-to-date licence from national regulators was lowest in Benin and Nigeria, where vendors in traditional markets are important antimalarial supply sources. The structure and characteristics of antimalarial distribution chains vary across countries; therefore, understanding the wholesalers that comprise them should inform efforts aiming to improve access to quality treatment through the private sector.
    PLoS ONE 04/2014; 9(4):e93763. DOI:10.1371/journal.pone.0093763 · 3.53 Impact Factor
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    ABSTRACT: The study examined the burden of out-of-pocket spending (OOPS) to households, because available data showed that OOPS dominates household expenditure on health in Nigeria. The study took place in rural and urban districts in Nigeria. A household questionnaire was used to collect data from 4873 households on their healthcare expenditures and payment mechanisms by using a 1-month expenditure recall period. Financing incidence analysis was assessed at the household level on the basis of socio-economic status (SES) groups and rural-urban location of the households. Concentration curves of OOPS were plotted with the Lorenz curve of total household expenditures to show the distribution of the burden of OOPS by SES compared with total household expenditure. The Kakwani index was computed to examine the overall progressivity or regressivity of OOPS. There was lack of financial risk protection for healthcare in the study area. The results showed that 3150 (98.8%) of payments were made using OOPS, nine (0.3%) using reimbursement by employers, one (0.03%) through private voluntary health insurance (PVHI), nine (0.3%) using instalment and 14 (0.44%) through 'others'. The average monthly household OOPS was 2219.1 Naira. The Kakwani index for financing incidence of OOPS was -0.18, showing that OOPS was regressive. The most-poor SES groups and rural dwellers experienced the highest burden of health expenditure. Urgent steps should be taken by the government to increase or enhance universal coverage in the country with financial protection mechanisms such as the National Health Insurance Scheme in addition to possibly abolishing some of the user fees that cause high incidence and burden of OOPS. Copyright © 2013 John Wiley & Sons, Ltd.
    International Journal of Health Planning and Management 04/2014; 29(2). DOI:10.1002/hpm.2166 · 0.97 Impact Factor
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    ABSTRACT: As agents for their patients, providers often make treatment decisions on behalf of patients, and their choices can affect health outcomes. However, providers operate within a network of relationships and are agents not only for their patients, but also other health sector actors, such as their employer, the Ministry of Health, and pharmaceutical suppliers. Providers' stated preferences for the treatment of uncomplicated malaria were examined to determine what factors predict their choice of treatment in the absence of information and institutional constraints, such as the stock of medicines or the patient's ability to pay.
    Social Science [?] Medicine 03/2014; 104. DOI:10.1016/j.socscimed.2013.12.024 · 2.56 Impact Factor
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    ABSTRACT: The Affordable Medicines Facility - malaria (AMFm), implemented at national scale in eight African countries or territories, subsidized quality-assured artemisinin combination therapy (ACT) and included communication campaigns to support implementation and promote appropriate anti-malarial use. This paper reports private for-profit provider awareness of key features of the AMFm programme, and changes in provider knowledge of appropriate malaria treatment. This study had a non-experimental design based on nationally representative surveys of outlets stocking anti-malarials before (2009/10) and after (2011) the AMFm roll-out. Based on data from over 19,500 outlets, results show that in four of eight settings, where communication campaigns were implemented for 5-9 months, 76%-94% awareness of the AMFm 'green leaf' logo, 57%-74% awareness of the ACT subsidy programme, and 52%-80% awareness of the correct recommended retail price (RRP) of subsidized ACT were recorded. However, in the remaining four settings where communication campaigns were implemented for three months or less, levels were substantially lower. In six of eight settings, increases of at least 10 percentage points in private for-profit providers' knowledge of the correct first-line treatment for uncomplicated malaria were seen; and in three of these the levels of knowledge achieved at endline were over 80%. The results support the interpretation that, in addition to the availability of subsidized ACT, the intensity of communication campaigns may have contributed to the reported levels of AMFm-related awareness and knowledge among private for-profit providers. Future subsidy programmes for anti-malarials or other treatments should similarly include communication activities.
    Malaria Journal 02/2014; 13(1):46. DOI:10.1186/1475-2875-13-46 · 3.49 Impact Factor
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    ABSTRACT: There is increased interest in using commercial providers for improving access to quality malaria treatment. Understanding their current role is an essential first step, notably in terms of the volume of diagnostics and anti-malarials they sell. Sales volume data can be used to measure the importance of different provider and product types, frequency of parasitological diagnosis and impact of interventions. Several methods for measuring sales volumes are available, yet all have methodological challenges and evidence is lacking on the comparability of different methods. Using sales volume data on anti-malarials and rapid diagnostic tests (RDTs) for malaria collected through provider recall (RC) and retail audits (RA), this study measures the degree of agreement between the two methods at wholesale and retail commercial providers in Cambodia following the Bland-Altman approach. Relative strengths and weaknesses of the methods were also investigated through qualitative research with fieldworkers. A total of 67 wholesalers and 107 retailers were sampled. Wholesale sales volumes were estimated through both methods for 62 anti-malarials and 23 RDTs and retail volumes for 113 anti-malarials and 33 RDTs. At wholesale outlets, RA estimates for anti-malarial sales were on average higher than RC estimates (mean difference of four adult equivalent treatment doses (95% CI 0.6-7.2)), equivalent to 30% of mean sales volumes. For RDTs at wholesalers, the between-method mean difference was not statistically significant (one test, 95% CI -6.0-4.0). At retail outlets, between-method differences for both anti-malarials and RDTs increased with larger volumes being measured, so mean differences were not a meaningful measure of agreement between the methods. Qualitative research revealed that in Cambodia where sales volumes are small, RC had key advantages: providers were perceived to remember more easily their sales volumes and find RC less invasive; fieldworkers found it more convenient; and it was cheaper to implement than RA.Discussion/conclusions: Both RA and RC had implementation challenges and were prone to data collection errors. Choice of empirical methods is likely to have important implications for data quality depending on the study context.
    Malaria Journal 09/2013; 12(1):311. DOI:10.1186/1475-2875-12-311 · 3.49 Impact Factor
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    ABSTRACT: Background Equity in health expenditure in low-income and middle-income countries is commonly analysed using benefit incidence analysis (BIA). In BIA, the monetary value of the subsidy associated with public sector health-care utilisation (approximated by the cost of the service) is attributed to each individual according to their frequency and type of health-care utilisation. The benefit distribution is measured according to socioeconomic status. Despite widespread within-country geographical inequalities in health status and public expenditure, BIA has rarely accounted for such differences. We investigate how results would differ if geographical inequalities were taken into account.Methods We carry out four versions of BIA for outpatient public health-care expenditure in Manica Province, Mozambique and compare the results. First, following standard practice, we rank individuals by socioeconomic status (measured by their household consumption) and we use average expenditure across districts to estimate the individual benefit. Second, we use a disaggregated measure of expenditure across districts to calculate the benefit. Third, we rank individuals by a measure of need for health care based on socioeconomic status and average district health status (measured by child mortality). Fourth, we combine the second and third approaches. We use data from the Household Budget Survey 2008/09, Census 2007, Ministry of Health, and Ministry of Finance records.FindingsWe find that the gap in benefit from public expenditure between highest and lowest quintiles widens substantially if differences in health status and expenditure across districts are taken into account, increasing from a ratio of 1·2 to 2·0.InterpretationResults suggest that the methods currently used may underestimate inequities in public health expenditure in contexts where geographical inequalities exist. Refinement of BIA using disaggregated data available from local institutions may improve estimates, stimulate local information systems' strengthening, and ultimately provide insights for a more equitable and efficient allocation of resources.FundingML and KH are part of RESYST, a health systems research programme consortium funded by UKaid from the Department for International Development. The views expressed do not necessarily reflect the department's official policies.
    The Lancet 06/2013; 381:S9. DOI:10.1016/S0140-6736(13)61263-5 · 39.21 Impact Factor
  • The Lancet 03/2013; 381(9872):1095-6. DOI:10.1016/S0140-6736(13)60757-6 · 39.21 Impact Factor

Publication Stats

3k Citations
612.71 Total Impact Points


  • 1993–2015
    • London School of Hygiene and Tropical Medicine
      • • Department of Global Health and Development
      • • Department of Disease Control
      Londinium, England, United Kingdom
  • 2014
    • University of Nigeria
      • Department of Community Medicine
      Nsukka, Enugu State, Nigeria
    • University of Yaoundé II
      Jaúnde, Centre Region, Cameroon
  • 2011
    • Eastern Mennonite University
      Harrisonburg, Virginia, United States
  • 2007
    • University of Liverpool
      Liverpool, England, United Kingdom