title: Estimating the cost of referral and willingness to pay for referral to higher-level health facilities: a case series study from an integrated community case management programme in Uganda.
abstract: BACKGROUND
  Integrated community case management (iCCM) relies on community health workers (CHWs) managing children with malaria, pneumonia, diarrhoea, and referring children when management is not possible. This study sought to establish the cost per sick child referred to seek care from a higher-level health facility by a CHW and to estimate caregivers' willingness to pay (WTP) for referral.
  
  
  METHODS
  Caregivers of 203 randomly selected children referred to higher-level health facilities by CHWs were interviewed in four Midwestern Uganda districts. Questionnaires and document reviews were used to capture direct, indirect and opportunity costs incurred by caregivers, CHWs and health facilities managing referred children. WTP for referral was assessed through the 'bidding game' approach followed by an open-ended question on maximum WTP. Descriptive analysis was conducted for factors associated with referral completion and WTP using logistic and linear regression methods, respectively. The cost per case referred to higher-level health facilities was computed from a societal perspective.
  
  
  RESULTS
  Reasons for referral included having fever with a negative malaria test (46.8%), danger signs (29.6%) and drug shortage (37.4%). Among the referred, less than half completed referral (45.8%). Referral completion was 2.8 times higher among children with danger signs (p = 0.004) relative to those without danger signs, and 0.27 times lower among children who received pre-referral treatment (p < 0.001). The average cost per case referred was US$ 4.89 and US$7.35 per case completing referral. For each unit cost per case referred, caregiver out of pocket expenditure contributed 33.7%, caregivers' and CHWs' opportunity costs contributed 29.2% and 5.1% respectively and health facility costs contributed 39.6%. The mean (SD) out of pocket expenditure was US$1.65 (3.25). The mean WTP for referral was US$8.25 (14.70) and was positively associated with having received pre-referral treatment, completing referral and increasing caregiver education level.
  
  
  CONCLUSIONS
  The mean WTP for referral was higher than the average out of pocket expenditure. This, along with suboptimal referral completion, points to barriers in access to higher-level facilities as the primary cause of low referral. Community mobilisation for uptake of referral is necessary if the policy of referring children to the nearest health facility is to be effective.
authors: Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18 A, SE-171 77, Stockholm, Sweden. nyonjoagie@gmail.com.|Malaria Consortium Uganda Office, P.O Box 8045, Kampala, Uganda. nyonjoagie@gmail.com.
authors: Agnes
authors: A
authors: Nanyonjo
authors: Malaria Consortium Uganda Office, P.O Box 8045, Kampala, Uganda. benbagoro@yahoo.com.
authors: Benson
authors: B
authors: Bagorogoza
authors: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, United Kingdom. Frida.Kasteng@lshtm.ac.uk.
authors: Frida
authors: F
authors: Kasteng
authors: Malaria Consortium Uganda Office, P.O Box 8045, Kampala, Uganda. gayebale@yahoo.com.
authors: Godfrey
authors: G
authors: Ayebale
authors: Department of Epidemiology and Biostatistics, Makerere University School of Public Health, P.O Box 7062, Kampala, Uganda. fmakumbi@musph.ac.ug.
authors: Fredrick
authors: F
authors: Makumbi
authors: Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18 A, SE-171 77, Stockholm, Sweden. goran.tomson@ki.se.|Medical Management Centre (MMC), Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18 A, 17177, Stockholm, Sweden. goran.tomson@ki.se.
authors: Göran
authors: G
authors: Tomson
authors: Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18 A, SE-171 77, Stockholm, Sweden. k.kallander@malariaconsortium.org.|Department of Epidemiology and Biostatistics, Makerere University School of Public Health, P.O Box 7062, Kampala, Uganda. k.kallander@malariaconsortium.org.|Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2A 4LT, UK. k.kallander@malariaconsortium.org.
authors: Karin
authors: K
authors: Källander
mesh_terms: D000328:Adult; D017028:Caregivers; D019090:Case Management; D002648:Child; D002675:Child, Preschool; D003153:Community Health Services; D003365:Costs and Cost Analysis; D003967:Diarrhea; D005260:Female; D005334:Fever; D005382:Financing, Personal; D006268:Health Facilities; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis; D008297:Male; D011014:Pneumonia; D012017:Referral and Consultation / Q000191:economics*; D011795:Surveys and Questionnaires; D014454:Uganda