Video Spotlight

"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.

Agnes Nanyonjo, Benson Bagorogoza, Frida Kasteng, Godfrey Ayebale, Fredrick Makumbi, Göran Tomson, Karin Källander and for the inSCALE study group

Malaria, pneumonia and diarrhoea are among the leading killer diseases among children aged five years and below. Efforts in realizing the Millennium Development Goals are tailored towards tackling the three diseases at community level through integrated community case management (iCCM). iCCM involves diagnosis and treatment of malaria, pneumonia and diarrhoea by community health workers (CHWs) in addition to referral of severely sick children, children whose conditions cannot be treated by CHWs, and newborns. However, slow implementation of the approach has been noted in the 75 ‘countdown’ countries which together account for more than 95 % of all maternal, newborn, and childhood mortality. 

One key component of integrated community approaches is a well functional referral system which has the ability to send referred cases to higher-level facilities. However, not all children referred to obtain care from higher-level facilities access referral treatment, indicating a gap in health services access. Previous studies have highlighted the challenges faced by caregivers of children referred, including problematic transport options, lack of money, competing responsibilities, perceived poor quality of care at the health facility and improvement in the child’s condition following pre-referral treatment. There is general agreement that the cost of referral must decrease to make referral completion an achievable goal. Moreover, the limited ability of first level health facilities to handle severely ill children in sub-Saharan Africa has been documented. There is also a general concern about the high out of pocket expenditure for health care among households in resource-poor settings, particularly health care sought from higher-level facilities. Furthermore, people are often willing to pay (WTP) for western medicine if the cause of disease is perceived to be biomedical. However WTP does not translate into actual expenditure; as the ability to pay is influenced by other factors. 

The evaluation of health care programmes and of the economic burden of disease is most meaningful when examined from a societal viewpoint, considering all costs, regardless of to whom they accrue, i.e. both health system and household costs, however studies with such analysis design are still scanty in low-income countries. The contingent valuation method, which elicits people’s WTP, can be used to measure the value attached to a health service delivery process, even in low-income countries. The stated WTP for referral can therefore estimate a caregivers’ valuation of referral and can be used as a basis for financial incentives fostering referral completion. This study used a societal perspective to examine average cost per child referred to a higher-level health facility as well as WTP for referral among the caregivers of the referred children. Such an approach is useful in identifying the brunt of costs borne by child caregivers in relation to service providers and can be used for planning interventions for a functional and integrated community referral system devoid of financial and economic barriers to referral completion.

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