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  • Title: Improving quality through cost recovery in Niger.
    Author: Wouters A.
    Journal: Health Policy Plan; 1995 Sep; 10(3):257-70. PubMed ID: 10151843.
    Abstract:
    New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements. In Niger, the role of improvements in the quality of health care in the context of health care financing reforms and cost recovery was explored in a 1993 pilot project. The project 1) supported drug availability by training health workers in diagnostic/treatment protocols using generic brands, 2) improved management systems and capabilities related to fee collection, and 3) installed systems for mobilizing additional resources at non-hospital facilities. Data on quality of care were collected using an evaluation of the cost recovery tests and through surveys of facilities and patients. In this study, quality of care was defined as the proper performance of safe, affordable, and effective interventions. This performance was measured at the structural, process, and outcome levels. Although implementation of the pilot program led to improvements in structural attributes of quality, significant gaps remained in the implementation of diagnostic and treatment protocols. The quality improvements put in place required significant investments in fixed and variable costs, and it is unlikely that optimal cost-effectiveness of services was achieved. In the test site of Boboye, copayment revenues covered 34% of the costs of medicines or 20% of the costs of drugs and cost recovery administration. In Say, user fees covered 50-55% of the costs of medicines (35-40% of drugs and administration). In Boboye, user fees plus additional taxes and copayments covered 120-180% of the cost of medicines (75-105% of drugs and administration). In-service training and other aspects of quality improvement were not covered. The sustainability of quality improvements rests with whether funds collected are rechanneled to pay for continued improvements.
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