Charlotte Michèle Dieteren

In low- and middle-income countries (LMICs), maternal mental health (MMH) during and after pregnancy is often neglected despite ongoing global efforts to reduce maternal mortality and morbidity. The complex nature of MMH problems and the stigma surrounding them require a thorough understanding of the perspectives of the different parties involved. Hence, we assessed the drivers of MMH problems, challenges in seeking help, and perceptions towards emotional and psychological support for pregnant women among four stakeholder groups in Western Kenya. A qualitative approach was taken to examine the perspectives towards MMH among mothers, fathers, nurses and community health workers (CHWs). Focus Group Discussions (FGDs) were organized among the four groups. Participants were drawn from three hospitals in Kisumu County, Western Kenya. The socio-ecological model for health behavior structured the analyses, with an initial deductive approach. The identification of specific themes within each level was conducted inductively. Additionally, suggestions for locally acceptable MMH care were collected. In total, ten FGDs were held with 73 participants. We found a large level of consensus among stakeholders regarding common causes, consequences and coping strategies for MMH challenges, such as poverty, stigma, intimate partner violence and a lack of social support. In contrast to mothers, fathers also highlighted domestic disputes stemming from disagreements over (resuming) sexual activity. Nurses predominantly mentioned medical consequences of MMH challenges, while CHWs had a more holistic perspective. Participants expressed a need and made recommendations for contextualized MMH care, particularly for a group-based intervention led by CHWs with partner involvement. The findings show that there is a need for MMH support in rural, low-resource settings. Mothers and CHWs showed a high level of convergence illustrating the importance of the liaison function of the CHWs between the nurses and mothers. Group-based MMH care was perceived as suitable by all stakeholders. The results of this study guided the design of an MMH intervention that was tested for feasibility and acceptability in the same setting.

Low- and middle-income countries (LMICs) house 66% of all hypertension patients, many of whom are undertreated, leading to severe health risks and higher healthcare costs. This study examined the required investments to improve hypertension control in Lagos, Nigeria, using real-world medical records and cost data. We analyzed routine medical records from 1249 hypertension patients across 74 public and private facilities in Lagos State and combined these with facility-level cost data to estimate the investment required to deliver guideline-based care. Patient-level gaps were extrapolated to the state level using prevalence-based scenarios, and linear random effects regression was used to assess associations between care completeness and blood pressure change. We found that adherence to consultations and medications according to guidelines was significantly associated with a 5-6 mmHg reduction in systolic blood pressure. These reductions correspond to a 6-14% decrease in cardiovascular complication risk and would require an average annual investment of USD 120 per patient. Medications are the main cost driver. Statewide, providing complete care for all hypertension patients would require a yearly investment of $300 million, or $5000 to $13,000 per saved life year. The identified required investments are currently far outside an acceptable range when compared to the Gross Domestic Product (GDP) of Lagos State, Nigeria. To make chronic care investments feasible, hypertension management must become more efficient, including reducing high medication costs through bulk purchasing, adopting innovative, group-based blended care models, and increasing health insurance coverage.

Introduction: Diabetes mellitus accounts for a significant share of morbidity and mortality in ages 30–70 years worldwide. In sub-Saharan Africa, diabetes care is often suboptimal for reasons ranging from health system weaknesses to patient illiteracy and non-compliance with recommendations. This study explores the potential costs and health benefits of optimising care for uncomplicated type 2 diabetes in Lagos State, Nigeria. Methods: Longitudinal data on medical care patterns and resource use (consultations, medications, diagnostics and lifestyle counselling) over a 1-year period were collected retrospectively from 84 health facilities in Lagos. Medical resource prices were obtained from a subsample of 26 facilities. Patient care gaps were assessed by comparing actual journeys to official diabetes management guidelines. Mixed-effect regression analyses were employed to explore the impact of care elements on blood glucose control and model the potential complications averted if all patients received recommended care, with extrapolation to the entire Lagos population. Results: Data from 642 patients with uncomplicated type 2 diabetes were analysed. A one-unit increase in consultation score (a measure of the adequacy of consultation visits) and having health insurance coverage were linked to 47-unit and 29-unit lower blood glucose levels, respectively. Optimising diabetes care requires US$3716 per patient annually, totalling US$2.1 billion statewide, with medications comprising 97% of costs. Enhanced care could reduce stroke and myocardial infarction by 2% (12 675 cases) and 4% (22 282 cases) over 7 years, respectively, at a cost of US$61 492 per complication averted. Conclusions: The investment required to optimise diabetes care in Lagos is currently unfeasible in the existing approaches. There is a need to explore innovative financing and delivery options, including digital value-based care interventions and cost-saving care approaches such as pooled medication procurement, while also investing in local medicines production capacity and expansion of the health insurance coverage.

In Sub-Saharan Africa, female entrepreneurs are well represented in healthcare but struggle to access financial services. Digital financing technologies could help close this gap. This study assessed the readiness, perspectives and gender disparities in (digital) loan characteristics among Kenyan health Small and Medium Enterprises (SMEs). We interviewed 24 and surveyed 410 health SME owners and retrieved loan-history data for 850 health SMEs. Appropriate parametric and non-parametric tests were used to compare key variables across groups, focusing on gender disparities. In addition, multiple regression analyses were employed to explore how different factors, particularly gender, influence uptake and characteristics of traditional and digital loans taken. In-depth interviews (IDIs) identified low trust in digital lenders, while survey results indicated a strong demand for loans, regardless of gender. SME owners willing to take risks (OR = 2.32, p = 0.052), with monthly financial needs (OR = 4.22, p = 0.001), and positive perceptions of digital loans (OR = 3.14, p = 0.004) were more likely to take a digital loan, compared to the low risk takers, those who never or rarely experience acute financial needs, and those with negative perception of digital loans, respectively. Loan-history data showed a gender difference in the initial traditional loan amount, with women-owned businesses receiving an estimated 47.7% less than the male counterparts (p = 0.022) however, this gap disappeared for digital loans. Over 50% of women-led businesses using digital loans experienced significant growth, suggesting increased digital revenues linked to these loans. This study underscores the financing gap faced by Kenyan health SMEs and demonstrates the potential of digital loans to improve financial inclusion, particularly for female entrepreneurs. It addresses a gap in the literature by providing new evidence on how digital financial products can reduce gender-based barriers in the health sector. Low trust in digital lenders, especially among non-users, highlights the need for improved information and transparency to foster confidence in these tools.

Low- and middle-income countries (LMICs) house 66% of all hypertension patients, many of whom are undertreated, leading to severe health risks and higher healthcare costs. This study examined the required investments to improve hypertension control in Lagos, Nigeria, using real-world medical records and cost data. We found that both adherence to consultations and medications according to guidelines was significantly associated with reduction of a 5–6 mmHg in systolic blood pressure. These reductions correspond to a 6–14% decrease in cardiovascular complication risk and would require an average annual investment of USD 120 per patient. The medication costs being the main cost driver. Statewide, providing complete care for all hypertension patients would require an annual investment of $300 million, or $5,000 to $13,000 per saved life year. The identified required investments are currently far outside an acceptable range when comparing to the GDP of Lagos State, Nigeria. To make chronic care investments feasible, hypertension management must become more efficient, including reducing high medication costs through bulk purchasing, adopting innovative, group based blended care models, and increasing health insurance coverage.

Background: International vertical health financing programmes risk functioning in parallel with existing domestic funding in low- and middle-income countries (LMICs), leading to inefficient service delivery and concomitant poor health outcomes. Aim: We assessed the opportunities offered by digitalised diagnostics (ConnDx) to target and monitor health funds to those in need objectively and transparently. Setting: ConnDx was rolled out in five private health facilities in Kisumu, Kenya. Methods: The ConnDx process was codeveloped with the local Department of Health of Kisumu. We used the quantitative data generated by ConnDx. We also calculated the costs for ConnDx and standard care to assess potential cost reductions. Results: In total, 2199 malaria cases were detected among 11 689 patients with fever. ConnDx allowed for the identification of malaria hotspots, semi-real-time assessment of patient health seeking behaviour across facilities and insights in doctor’s prescription behaviours. Based on these insights, we estimated a 25% reduction in costs can be realised, while simultaneously better quality indicators can be monitored. Conclusion: The concept of ConnDx can be used for any medical condition that can be diagnosed in a digital manner and linked to mobile payment systems. The generated data can contribute to better quality services for individual patients while at the same time support local health policy makers and managers for more targeted interventions. Contribution: The ConnDx approach can help decision makers in LMICs to channel disease-specific funds to the right patients for the right disease at the right time, which can potentially accelerate the way to universal health coverage.

Objective There is a need to reduce inefficient service delivery caused by parallel financing streams. In this paper we aim to assess the opportunities offered by digitalized diagnostics to target and monitor health funds to those in need objectively and transparently. Methods In this study we used the malaria case to demonstrate the ConnDx process codeveloped with the local Department of Health of Kisumu, Kenya. We used quantitative data to demonstrate how an ConnDx approach can contribute to manage malaria health funds with markedly increased transparency. We also calculate the costs for ConnDx and standard care to assess potential cost reductions. Results ConnDx was rolled out in five private healthcare facilities and detected 2,199 malaria cases among 11,689 patients with fever. ConnDx allowed for the identification of malaria hotspots, semi-real-time assessment of patient health seeking behavior across facilities, and insights in doctor’s prescription behavior, vis a vis National Guidelines. Based on these insights, we demonstrate that a 25% reduction in costs can be realized, while simultaneously better-quality indicators can be monitored and put into quality improvement action. Conclusion The concept of ConnDx can in principle be used for any medical condition that can be diagnosed in a digital manner and linked to mobile payment systems. This can help decision makers in LMICs to channel disease-specific funds to the right patients for the right disease at the right time, which can potentially accelerate the way to universal health coverage.

Background: Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.Methods: A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).Results: We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.Conclusion: Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.Trial registration: PROSPERO registration numberCRD42022340059.

Background: Many governments in low- and middle-income countries (LMICs) have difficulties paying healthcare costs upfront leading to high out-of-pocket payments for patients. A Development Impact Bond (DIB) is an innovative financing mechanism in which pr ivate investors provide pre-payment of development program expenses. At the same time, public agencies or donors repay the investor’s investment with a reasonable interest rate if the program succeeds in delivering independently measurable results that are contractually agreed upon. This study assessed quantitatively and qualitatively the feasibility of a DIB for hepatitis C Virus (HCV) diagnosis and treatment in Cameroon. Methods: A revolving fund of up to €230,000 was made available by the investor. The outcome payor reimbursed the investor only in case of good performance, defined as cured patients (HCV-RNA negative). HCV carriers who were identified were referred for treatment and tested for cure 12 weeks after completion of treatment, the outcome being validated by an independent assessor. The evaluation was guided by the six-agents model, involving interviews with relevant stakeholders (N= 22). Results: In total, 253 (98%) patients completed treatment, of which 244 (96%) are cured at week 24. We estimated that the average per-patient outcome payment for HCV diagnosis and treatment is €1,542, and the average costs per treated patient is €1,858. The investor was fully repaid, including the agreed interest and bonus. Themes or findings from the interviews confirmed the feasibility of a DIB in a low-resource setting. Conclusions: This study demonstrates that a DIB can be a suitable financing mechanism for HCV services, supporting the path towards elimination. When governments in LMICs do not have sufficient resources to fund such elimination programs upfront, such public-private partnerships can offer a solution.

Introduction The burden of non-communicable diseases (NCDs) has increased substantially in low- and middle-income countries (LMICs), and adapting health service delivery models to address this remains a challenge. Many patients with NCD seek private care at different points in their encounters with the health system, but the determinants and outcomes of these choices are insufficiently understood. The proposed systematic review will help inform the governance of mixed health systems towards achieving the goal of universal health coverage. This protocol details our intended methodological and analytical approaches, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methods and analysis Following the PRISMA approach, this systematic review will develop a descriptive synthesis of the determinants and outcomes of private healthcare utilisation for NCDs in LMICs. The databases Embase, Medline, Web of Science Core Collection, EconLit, Global Index Medicus and Google Scholar will be searched for relevant studies published in English between period 1 January 2010 and 30 June 2022 with additional searching of reference lists. The study selection process will involve a title-abstract and full-text review, guided by clearly defined inclusion and exclusion criteria. A quality and risk of bias assessment will be done for each study using the Mixed Methods Appraisal Tool. Ethics and dissemination Ethical approval is not required because this review is based on data collected from publicly available materials. The results will be published in a peer-reviewed journal and presented at related scientific events. PROSPERO registration number CRD42022340059