The results have been reported using themes which are structured into five main sections, with section one presenting evidence from the literature highlighting the research gaps which this paper addresses and the remaining sections exploring findings from the KIIs. Section two explores the views of participants on financial decision making processes at the national and county levels in Liberia. While section three explores the roles within financial decision making at different levels. Section four presents challenges with financial processes and planning at each level, whilst section four discuses out-of-pocket (OOP) costs. Section six details opportunities and recommendations for NTDs financing in Liberia and finally, section seven colligates findings from the evidence summary of the literature in LMICs and Liberia specifically.
4.1 Evidence summary from LMICs and Liberia
Economic evaluations and modelling of SSSDs interventions
The predominant source of evidence from economic evaluations comes from two systematic reviews, which cover onchocerciasis and lymphoedema interventions[18,19]. One Individual studies were also identified for yaws and hydrocele interventions, although no economic evaluations were found for the latter [20]. No studies reported on BU interventions and also, there were no economic evaluations for integrated case management.
The current literature lacks evidence on SSSDs costing, partially since the term SSSDs is relatively novel, although the evidence for MDA is also scarce [21]. Even when SSSDs are grouped with NTDs, there remains a gap in costing of services of the various pathways for seeking care, such as the direct and indirect costs associated with care seeking, feeding for both patient and caretaker, transportation, in-patients incur costs on toiletries and food items (daily food rations may not be enough for patient and family) [22]. Patients also underwrite costs of medications when there are stockouts and those admitted to in-patient care lose out on potential earnings, with the length of stay ranging from weeks, typically in LF patients, to years in individuals with leprosy[22, 23]. Even after being discharged, patients underwrite the costs associated with traveling back home, highlighting a cost implication which has not been costed in Liberia.
To the best of our knowledge, there have been no comprehensive costing studies conducted for SSSDs or NTDs in Liberia except for one study done by Popovic, et al. (2017) that reviewed Marginal Budgeting for Bottleneck (MBB), Core+ and the One Health tool as costing tools that have been used in Liberia for core services, such as basic health packages[24].
Across other LMIC settings there was only four papers of economic evaluations on SSSDs, and of these, only one adopted the patient perspective[22]. Also, whilst these studies present evidence of available Economic Evaluations for lymphoedema and onchocerciasis, there is a lack of evidence regarding yaws, hydrocele and BU, as illustrated in table three [18, 20, 23, 25]
Table 3: Summary of the economic evaluations in LMICs reported in the literature review
Condition
|
Intervention(s)
|
Studies Reporting
|
Best Cost-effectiveness
|
Best Cost-Benefit
|
Hydrocele
|
Surgical interventions
|
Yellu (2010)
|
NA
|
NA
|
Yaws
|
Sequential testing: treponemal RDT before a trep/non-trep RDT
|
Fitzpatrick 2017
|
ICER is US$ 58 (42–103) per correct diagnosis gained
|
NA
|
Onchocerciasis
|
Ivermectin MDA (OCP, APOC, or Annual MDA)
|
Turner 2019 (plus 8 CBA and 7 CEAs included in this);
Kim 2015
(non-E.E.s reporting economic info on interventions:
Boussineq 2018; Turner 2013; Verver 2018 – see text below)
|
See table 2 of Turner 2019
e.g.
$13.4 per healthy life-year added (Benton 1998, APOC, cost horizon 1996-2017),
$7 per DALY averted (Remme et al 2006; APOC; cost horizon 25 years)
|
See table 3 of Turner 2019
|
Lymphoedema
|
MDA (drug combinations unclear) (e.g. GPELF)
|
Gedge 2018 (and 12 E.Es included in this)
|
See table 1 of Gedge 2018
e.g. $5.90 per DALY averted (Ottesen 2006, Annual MDA, 30 year time horizon).
|
See table 2 of Gedge et al 2018
|
Crucially, we found no studies which investigated how the integration of SSSD and other NTD programmes affect programmes’ costs and cost-effectiveness. A paucity of information on productivity losses experienced by informal caregivers.
Key findings for Liberia
In Liberia, a full package of costing for the health system inclusive of costing of NTDs or specific skin diseases, has not been conducted [2]. To the best of our knowledge, there is no literature on financing or costing of NTDs or SSSDs, and information on costing projects in Liberia is scarce. According to the literature, there is currently no costing being conducted for SSSDs in Liberia up to the time of writing this evidence summary. However, it is unclear if the lack of literature is due to a lack of costing being conducted in Liberia, or rather a lack of reporting [14].
Costing tools previously piloted in Liberia include CORE Plus by MSH in 2009; the WHO’s MBB tool for health and nutrition interventions of the Millennium Development Goals [24]. Also piloted, were USAID’s One Health tool used for HIV & AIDS interventions and their database developed for costing services to support policy and decision making at the MoH [24]. Among these piloted tools, the MoH has selected the USAID supported database as the accepted tool for costing services in Liberia. The main reported drawback of the tool is that it is not web based [14]. However, for uniformity purposes, the MoH has recommended the use of this database costing tool for all partners supporting the Ministry through implementing costing services in Liberia [14].
Recommendations for further work
Building on the literature review findings, the authors recommend the following areas be addressed in future research. Firstly, the knowledge gap in the costing of SSSDs care in Liberia from societal and patients’ perspective must be addressed. Cost-effectiveness analyses of SSSD interventions in Liberia should also be conducted to identify cost drivers and incremental cost differences, to help guide SSSD policy and programs. This preparatory study for the wider REDRESS research project will contribute towards filling some of these critical evidence gaps.
4.2 Financial decision making processes
Many participants highlighted that the Ministry of Finance and Development Planning produce the projection for line Ministries and Agencies and bring it to the national legislature for approval. The approval budget is then presided over by the Ministry of Finance and Development Planning and the MoH like other ministries are required to make requests based on priority activities and the availability of funds.
National level
Six national managers stated that financial decision making usually occurs in sector and strategic coordination meetings, among others where local county and district health authorities are not represented. However, other managers highlighted that the financial decisions are made internally by departments, before going to the general coordination meeting.
“OK, government’s own competing priorities exist, so, therefore, department directors usually call meeting for us to internally agreed on some decision before going to general coordination meeting” National level key informants, 029, Monrovia
County level
Respondents from all levels said that financial decisions at the county and district level are limited in many ways for the general health system. For example, in procurement of goods for the health system at county level, there is a benchmark of not exceedingly more than US$10,000.00 per quarter when procuring goods for all programs, inclusive of the NTDs program. Seven participants explained that financial decisions are made through the different programs supervisors who usually participate in fiscal planning and forecasting meeting on a yearly basis at the county level. However, whist these forecasts are sent to the national level, they are not binding, and may not be used by the national office. Rather, other program financing instructions are sent from the national level to the county with an approved budget and direction for the usage of the approved budget. Four county level participants expressed that the county authorities have no power to alter the financial decision made at the national level, even when it does not align with priorities. A similar situation was described in both ICMP and non-ICMP counties.
“Our plan is sent to national level. If it is sent, national too and her partners consolidate all those plans. For NTD for example, all those partners that are supporting NTD activities will say I can support this one. National level will plan and communicate their plan. And it comes with budget line which at county level you cannot divert so easily. So, if you will divert it, it must be communicated. So national level too will send a budget line and you go straight by the implementation of what the budget lines states. ….” County level key informant 012, Grand Gedeh County
“Financial decisions are made through the management of the Central office. Before finances are provided usually the County makes their request to national. So, the request national will look at it and either leaves it like that or adjust based on the availability of resources. And when finances come, they come with template on how it should be utilized. So, the leadership along with the NTDs team or surveillance team as well as others make decisions based on the guide that is provided for implementation by national. So, this is how decisions are made” County level key informants, 018, Lofa County.
Overall, financial decentralization for NTDs is not yet achieved, but for other budgets such as Malaria control program, Community Health programs, Health Promotion, Non-Communicable Diseases and the Tuberculosis (TB) control program decentralisation has been achieved. Our findings suggest that financing (including information) for NTDs remains centralized and largely donor driven.
District and health facility levels
Almost all the Officers in Charge and District Health Officers interviewed confirmed a lack of power to decide or participate in financing discussions and decision making at the district and facility level. They explained that they only receive supplies and materials upon request.
“At this level, we receive only supplies of materials do not cash or making financing decision. When our materials are finished, we can write the county and the county write national or the county supply us what we want when they have the money to buy them” District level key informant 021, Grand Gedeh County
In summary, national level actors are charged with an authoritative fiscal planning, while county level actors are informing fiscal planning by providing suggestions to national level for inclusion where applicable. Conversely, district and facility level decision making is minimal.
4.3 Financial decision making
This section explores the different roles within financial decision making, in terms of key actors involved, funding sources and donor contributions.
Who is involved?
Participants from all levels agreed that financial decisions for general health programme are being made through planning with partners and the MoH, with NTD financing decisions made through the NTDs ICMP. However, most of the respondents noted that financial decisions are highly directed by program and donor who provide the funding for the implementation of the program.
“Thank you very much. So, the roles of most of our partners were incredibly positive, they served primarily as funding partners and facilitators. They helped to provide pool of information resources that helped to inform our plan but they did not direct what the plan could be made of, they did not direct what were the priorities; but rather, they provided that support to the ministry of health while the ministry of health and Liberians led the development of their own plan, making decision priorities through sector meetings and strategic coordination meeting……” National level key informants 008, Monrovia
Other managers from the national level stated that financial decisions require the approval of the MoH and signed memorandum of understanding between the MoH and partners, such as ACTs (formerly MAP) who serves as an independent financial body to manage and report on partners resources on behalf of the MoH.
“Alright so like the financing of drugs, the procurement of drugs, and medical supplies for NTDs interventions, the approval has always been the ministry of health even though the case management comes from and manage by ACTs formally MAP, but whatever request, budgets, memorandum of understanding can be signed between the ministry of health and the partners and then of course the third party ACTs, so whatever implementation that’s supposed to be done here that request is being approved by the office of the chief medical officer and then before it is being implemented, be it request of procurement of drugs and medical supplies” National level key informant, 007, Monrovia
Sources of funding
As previously observed, funding for NTD services within Liberia is highly donor dependent in both case management and non-case management counties. However, there were more gaps described in non-case management counties, for example Grand Gedeh compared to Lofa.
According to almost all national level participants, the government’s funds and contributions to the health sector been scarce, except for malaria programmes where they provide approximately 60% of the cost to run malaria programs and purchase drugs. More than five participants asserted that for other diseases including NTDs, the government contribution goes towards personnel and office costs, contributing only 1% of the overall program cost for NTDs services nationally. The cross-reference table 2 above shows the 2018/2019 Fiscal year budget and expenditure in percentage point of government contributions to health system strengthen in Liberia.
Ten national level participants asserted that government funding contributes towards human resources and salary payments through the government’s Civil Servant payroll system, with the offices and government buildings being used for health services.
“Well, as I told you, with Human Resource, the salaries are paid the government, the office space and building but all other expenditure, 100% depend on partners whether preventive chemotherapy, whether case management, everything depends on partners” National level key informant, 003, Monrovia
Donor contributions
In this section, our findings represent views about donor funds and in-kind support (not Performance Based Financing). Some of the National level managers expressed that the donor funding or in-kind support consisted of support to standalone programs like HIV/AIDs or TB/leprosy, among other programs.
“Umm, first of all, you know the ministry activity is not very programmatic if it comes to the budgeting aspect, so you will not find most of these things being flag out as a standalone activity, except for those that have been donor focused like the HIV and AIDs, like TB and leprosy, like TB and malaria those are things that stand alone because they have particular commitment and agreement with the ministry, but other than those you have all other services being done generally from the government perspective, except for donor in kind support or donor commitment to different focused programs that are donor specific in kind support or direct funding” National level key informants, 030, Monrovia.
Other national managers also highlighted that the donor funding or in-kind support consisted of medicines and medical products (Preventive chemotherapy drugs) donated by pharmaceutical companies, with distribution funded through programs like that of LSTM, SCI and Sightsavers.
Leprosy Multidrug Therapy drugs are donated by Novartis, while American Leprosy Mission has funded laboratory reagents and deploys Gifts-In-Kind shipments, including other medicines and products. This illustrates that donor financing and in-kind contributions account for most medicines and consumables for Liberia’s NTD program.
“Yes, sure but we do provide services and bulk of those in-kind support and funding come from partners and you know, partners donate them us, included are those medical, medicines and medical products ……” National level key informants, 001, Monrovia
Other national managers stated that the donor funds or in-kind support finances the $5 package support[4] to CHAs and CHVs who identify potential cases, with remaining funding going towards personnel salaries.
4.4 Challenges with financial processes and planning
Participants highlighted quantification and planning, inadequate government involvement and donor involvement as key challenges.
Quantification and planning
Quantification of goods and budget estimating were specific challenges described, given the high donor involvement and limited government role currently. National Managers expressed that quantification was done with partners in quantification meetings with minimum government participation.
“We usually do quantification in our quantification meeting with all the partners in attendance. Although, the government has limited role and county pharmacists from the 15 counties cannot be in all the meeting but we something look at their report to know the previous consumption level” National level key informants, 008, Monrovia.
Our findings demonstrate that decision makers for NTDs are not being represented during quantification, with attendees unaware of the actual supply needs for the NTDs program. National level participants stated that there are no NTD representatives in quantification meetings, with projections for NTD drug needs based on assumptions of attendees. Attendees usually includes members of the supply chain, health promotion and pharmacy departments. This was echoed by managers at the district and facility levels, who highlighted financing discussions and budgets as challenges, owed to their limited or non-existent decision-making power.
To further complicate the quantification decision making process, participants highlighted that partner involved in the normal protocol for drug quantification are not the same as the NTD partners, leading to frequent stockouts due to inaccurate estimates.
“I have not seen NTDs representative from the department during quantification meeting like Pharmacist or so. We have been looking at the previous supply records and assumptions. I am sure they will be represented in future quantification. I think it is a good idea to have someone representing them like pharmacist or so” National level key informants, 010, Monrovia.
Limited government involvement in NTD financing
Participants across all levels agreed that there is a lack of budgetary allocation for SSSDs financing at the national and county level, with support limited to MDA and no government allocation towards case management of people affected [1,21]. Most district level participants also noted inadequate funding at the district and facility level,
“With regards to SSSD, there is no budget allocated at national and the county levels. Yeah, but usually what happen, we only receive budget when it comes to Mass Drug Administration (MDA), to distribute drugs throughout the entire country for everyone especially ages from five to fourteen ” county level key informant, 005, Lofa County
While five other County level managers stated that the salary payments by the government are marked by huge discrepancies in salaries among clinicians which is yet to be addressed by the Civil Service Agency and the Ministry of Finance. Moreover, participants across all levels agreed that stockouts of medication and supplies at facilities, combined with delayed salary payments are driving low staff attendance and retention. District level participants suggested activities for addressing these challenges, including focusing on improving personnel retention and management.
“Yes, the government paid salaries which have had discrepancies with payments among clinicians which is beyond our control; from civil service and the Ministry of finance, we have been talking about it and engaging them but no result. I am a nurse, and you are nurse maybe I make US$140.00, and you make US$250.00 and the both of us are nurse” County level key informant 022, Grand Gedeh County
County level staff expressed different views; for example, one participant identified that government funds consisted of fuelling the ambulances, while another stated that funds are directed at the county level, with special instructions on its implementation, such as for fuelling the generators, or gasoline for motorbikes.
Donor support and involvement for NTDs
Donors coordinate around the integrated case management and supply different goods and support other parts of the process as part of that in the ICMP counties with noticing of once sever frequency of drug stockouts per month as compared to non- ICMP where supply also depends on NGOs and other donors with limited government support but with big gaps and more than three times sever frequency of monthly drug stockouts.
4.5 Out-of-pocket costs
Participants across all levels agreed that limited funding has implications for the quality of services, one of which is that patients are forced to pay OOP costs for care e.g., blades for diagnosis, prescriptions if stock outs occurs and transport costs.
“When the patient is discharged, remember you took them to the hospital through the ambulance and the patients themselves have to take care of the issue of food, toiletries, and other things such as accommodation for caregivers. When the patient is discharged, the patient supposed to come home, who takes care of that transportation cost to come home? Is the patient” Health facility level key informant 019, Grand Gedeh Count.
The greatest challenge highlighted by patients and community level participants were out-patient expenditures on transportation (with patients often refused motorbikes or overcharged, due to fear and stigma), medication and food/toiletries if in-patients.
Conversely, all county level managers stated that that OOP usually consist of purchasing antibiotics, sore dressing materials and gauze during stockouts at the county and facility level. This was the most expressed view.
“What is done for patient, we just do our ordinary antibiotics that may be available. But sometimes we tell patient to buy these things. Most especially when the dressing materials from the county level are not available. We tell patient please get your gauze despite the needed gauze from the NTD belt is not there so that we can use the initial dressing till the NTD gauze can come or until they call their county NTD focal person can come” County level key informants 014, Grand Gedeh County
Who is responsible for paying out-of- pocket costs?
All patients, household heads and community leaders agreed that communities share costs for transportation/support for food. This was the most expressed view.
“Mainly it is the patient that bears the cost during stockout of medications at the facility and then the patient came to seek care, you will find out that the patient will be given prescription to go and purchase their medication. And whenever patient do not have money, it become serious problem for the patient” Health facility level key informant 019, Grand Gedeh County
District and facility level managers stated that family members or caretakers bear the cost for OOPs, with others reporting that costs are sometimes covered by advocates, through health worker appeals.
“It is the family that bear the cost. Like I said, it is family because if the family does not have money, then the advocates in the community, because if somebody come with NTDs condition and they are treated and there is no funding for them to go back home they cannot stay in the hospital. You go and appeal and advocate for them and say, oh, we got client and I am finished with their treatment, so we want them to go back home. Sometimes and also, we negotiation alternatives like if any car is going in the same direction, we can talk to them to help the person by giving them lift in their car……” Community level key informant 020, Lofa County
Six community level participants expressed different views from other community leaders and household heads. For example, four participants stated that OOP costs often fall on the shoulders of patient’s relatives and family members. While two participants stated that the burden is usually directed to the clinicians providing the services, to the extent that sometimes they are forced to use petty cash authorized by the CHO (County Health Officer) to transport patients home.
“The costs are sometime shouldered by the patients’ relatives or the clinician providing the service through CHO bears the cost, if petty cash is available for help” Community level key informant 021, Lofa County
Financial implications of out-of-pocket payments for people affected and their families
Three community level respondents highlighted how OOP expenses force individuals to weigh up the cost of seeking care and loss of earnings with the benefit of receiving care.
“I have to encourage my uncle and took him to the hospital. he did not want to go to the hospital because the hospital is far from our town, and he thinks that if he goes there, he will miss on the opportunity to get our daily meal through fishing and farming and doing daily work for other to earn food money…” Community level key informant 022, Grand Gedeh County
4.6 Opportunities and recommendations for NTD financing
Our results demonstrate that whilst NTD services are provided in the ICMP counties, the quality of these services is undermined due to inadequate funding, leading to stockouts, etc. Respondents suggested different avenues for generating additional funding to strengthen the quality of care, including budgeting at county level, public private partnership, county social development funds and reintroduction of user fees.
At present, NTD care services include free management services for NTDs, such as screening, lab testing/specimen collection and diagnosis, medication, and complication management. These services are usually free in the five piloted ICMP counties, compared with non-ICMP counties where only annual MDA and standard care are provided free of charge. Moreover, complicated cases from ICMP or Non-ICMP counties are often referred to the referral hospital or to Ganta Rehab (Leprosy rehabilitation centre), with patients and care takers from ICMP counties provided with ambulance transportation, medication, and treatment free of charge.
Eleven key informants highlighted opportunities for NTDs and general health system financing in Liberia. One participant suggested that the reintroduction of fees for service or cost sharing could help solve the stockouts observed over the years.
“The reintroduction of payment system as the fee for service or cost sharing will help solve the stockouts problems, where minimum fee is charge for the service” County level key informant 014, Grand Gedeh County
While several participants viewed private sector partnership as an opportunity for NTD financing in Liberia, others emphasized that increasing awareness of NTDs/SSSDs, perhaps via radio, will call the attention of private investments in financing these diseases.
Others emphasised opportunities for NTD Financing through the County Health Board, which is chaired by the political leadership of the county (Superintendent), someone perceived as having the political power to influence resource allocations for development financing.
Two county level managers stated that an additional opportunity for NTDs/SSSDs financing might be through the county social development funds[5] and individual citizen donations.
“As an innovation, let start thinking about using the county social development funds and also individual contribution to the financing of NTDs/SSSDs in our country since it is affecting our people” County level key informant 028, Nimba County
[4] CHVs are provided with $5 incentive for each confirmed NTD case they identify.
[5] Social Development Funds – are the resources paid by concessionaries companies to the county in the form of social corporate responsibilities. These monies are pay annually on a regular basis.