1. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Economic Evaluation of Flying Doctor Services in KZN – South Africa Emmanuelle Daviaud, Mickey Chopra Health Systems Research Unit, Medical Research Council. Cape Town, South Africa

2. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Purpose of Study  Access to clinical specialist care is uneven and very often poor in developing countries  Two possible approaches to increase access  Getting the patients to the specialists (referral option)  Getting the specialists to the patients (outreach option)  Policy makers require a good understanding of the opportunity costs incurred by each form of intervention.  We therefore conducted an economic evaluation of a air outreach programme in a rural province in South Africa in 2004.

3. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Outreach: the Flying Doctor Service Run by NGO: Red-Cross AMS in collaboration with DoH  DoH staff & volunteers (NGO, private sector) are flown for 1 day to rural district hospitals. There they:  See pre-selected patients in OPD and perform Surgery.  Provide training and support for junior doctors in rural hospitals  Update protocols, check quality of care  Each hospital visited at least once a month  Air service provides cold chain delivery system for blood, vaccines, drugs, labs samples, etc

4. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 The questions  What is the cost per patient of the actual outreach service ?  What would be the cost with a referral-based model for delivering similar level of service?  Economic analysis, not clinical analysis  Benefit for the patient in terms of access and decreased cost, whilst undeniable, is not quantified in this study.

5. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Methodology A.2004 F.D.S. activity and cost to the public sector were analysed. B.Activity in regional and tertiary hospitals which would have taken place, if outreach was not available, was quantified and costed. C.Cost of A & B were compared. D.Sensitivity analysis carried out

6. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Modelling Referral Option Survey of Clinicians:  From patients seen in Outreach and per clinical type, what proportions would apply if Referral- based model:  % would not receive service  % would be referred to regional & to tertiary hospitals  % of those referred who would require ambulance transport

7. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Activity

8. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Costs Outreach

9. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Costs Referral Model

10. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 RESULTS

11. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Outreach Activity in 2004  Over 19 000 patients were seen  85 were referred on to regional/tertiary hosps  451 patients had surgery  457 clinics were held in 30 hospitals  672 staff attended CPR course  2176 attended special lectures

12. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Type of consultations

13. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Volunteer Staff

14. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Patients Distribution with Referral Model

15. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Activity Referral Model

16. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009

18. Comparing Costs

19. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Sensitivity Analysis

20. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 DISCUSSION  Outreach based model cheaper for higher coverage  Well-suited for higher density rural areas  Requires good management of outreach to ensure that:  Outreach staff is reminded of duty days  Patients are pre-selected in receiving hospitals  Both Access AND Efficiency addressed

21. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 What was not quantified  Impact of training of junior doctors  Impact of quality monitoring in rural hosps  Impact of personal contact between consultants and junior staff  Impact on patients (cost and proximity)  Savings on cold chain transport