Public Primary Health Care Services Research Articles

Reflections of nurses and primary healthcare managers on integrating hospital at home into public primary healthcare services: a Norwegian focus group study

Background Hospital at home (HaH) is an innovative approach to healthcare delivery that brings specialized services to patients’ homes. HaH services are typically available in urban areas where hospitals can easily reach nearby patients. An integrated care model that utilizes the public primary healthcare system may extend HaH services to include patients residing further away from hospitals. However, there is limited evidence of primary healthcare employees’ views on integrating HaH care into primary healthcare services. This study aimed to explore the reflections of primary healthcare employees on integrating HaH care into primary healthcare services. Methods Ten focus group interviews were conducted with homecare nurses and managers of primary healthcare services in five municipalities in Mid-Norway. Reflexive thematic analysis was used to analyze the data. Results The analysis resulted in three key themes regarding the integration of HaH care into primary healthcare. Participants discussed how they capture the distinctiveness of HaH care within the primary healthcare landscape. Moreover, they identified that the introduction of HaH care reveals opportunities to address challenges. Lastly, the study uncovered a strong primary healthcare commitment and a sense of professional pride among the participants. This resilience and dedication among primary healthcare employees appeared as an incentive to make the integration of HaH work. Conclusions This study offers valuable insights into integrating HaH into primary healthcare services, highlighting opportunities to address challenges. The resilience and dedication of primary healthcare employees underscore their commitment to adapting to and thriving with HaH care. To establish a sustainable HaH care model, it is important to address geographical limitations, consider the strain on providers, maintain robust relationships, enhance funding, and formalize decision-making processes.

Effects of performance-based capitation payment on the use of public primary health care services in Indonesia

The Indonesian national health insurance agency BPJS Kesehatan, the largest single-payer system in the world, is among the first to combine capitation-based payments with performance-based financing. The Kapitasi Berbasis Komitmen (KBK) scheme for puskesmas (community health centres) was implemented in province capitals between August 2015 and May 2016. Its main goal was to incentivize the substitution of secondary by primary care use. We evaluate its effect on its three incentivized outcomes: the fraction of insured visiting the puskesmas, the fraction of chronically ill with a puskesmas visit and the hospital referral rate for insured with a non-specialistic condition. We use BPJS Kesehatan claims data from 2015 to 2016 from a stratified one percent sample of its members. Comparable control districts were identified using coarsened exact matching. We adopt a Difference-in-Differences (DID) study design and estimate a two-way fixed effects regression model to compare 27 intervention districts to 300 comparable non-capital control districts. We find that KBK payment increased the monthly percentage of enrolees contacting a puskesmas with 0.578 percentage points. This is a sizeable increase of 48 percent compared to the baseline rate of just 1.2% but it still leaves most puskesmas far below the “sufficient” KBK threshold of 15%. For chronically ill patients, a small increase of 1.15 percentage points was estimated, but it leaves the rate even further below the program's “sufficient” threshold of 50%. We find no statistically significant effect on referral rates to hospitals for conditions not requiring specialist care. While we find positive effects of KBK on two out of three outcomes, all estimated effect sizes leave the actual rates far below the program targets. Our findings suggest that the KBK performance-based capitation reform has not been very successful in substituting secondary care use by greater primary care use.

Introducing New Paths towards Public Primary Healthcare Services in Greece: Efforts for Scaling-Up Mental Healthcare Services Addressed to Older Adults.

The exponential growth in the aging population challenges the Primary Care Providers (PCPs) who provide health care services to older adults who are considered highly vulnerable and are in need of specialized healthcare services. The development of new policies and the adoption of appropriate health strategies by PCPs may improve the early detection and prevention of mental disorders in older adults. This reduces both queuing and costs in outpatient clinics while preventing stigma for patients and families. To this end, specialized training for PCPs at the Local Primary Health Care Unit (LPHCU) was provided in order to conduct efficient assessments of older adults (65 and above years old, without previously diagnosed depression or dementia, and willing to participate). The assessment is based on the Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS). Older adults identified with MMSE <20 and GDS >5 were referred to the psychiatric outpatient clinic. The aim of this study is to discuss evidence-informed policymaking in Greece with a focus on advancing mental health practices and scaling up quality primary healthcare services for older adults.

Sociodemographic and health profile of asylum-seekers in Rio de Janeiro, 2016-2017.

ABSTRACTOBJECTIVE To analyze the sociodemographic profile and self-reported health conditions of asylum-seekers in Rio de Janeiro.METHODS A cross-sectional study of secondary data, collected from asylum claims forms completed in 2016 and 2017, at Cáritas Arquidiocesana do Rio de Janeiro (Cáritas-RJ). Descriptive analyses were performed and absolute and relative frequencies and 95% confidence intervals were calculated.RESULTS Claims completed by 818 asylum-seekers from 49 different countries were identified, of whom 126 (20.3%) were stateless, 510 (62.7%) were male, 797 (97.4%) were adults, with a mean age of 30.5 years, 551 (73.5%) were single, 340 (44.1%) had higher education, and 27 (4.0%) were unemployed in their country of origin before coming to Brazil. Fear of persecution for political opinion, violation of human rights, and risk of torture stood out among the reasons stated for requesting asylum. To reach Brazil, 629 (80.5%) traveled only by plane. Regarding health conditions, 216 (29.0%) reported having some symptom, disease or health problem, the most frequent being pain, vision problems, infectious diseases (including HIV/AIDS), and hypertension. Only 15 individuals (2.2%) reported being in some medical or psychological treatment; 42 (6.0%) reported visual impairments, 14 (2.0%) reported physical impairments and 4 (0.6%) hearing impairments.CONCLUSIONS Unlike other countries, where forced migrants with a low level of education enter clandestinely by sea or land, asylum-seekers residing in Rio de Janeiro between 2016 and 2017 were mostly adults with higher education who migrated using air transport. They had primary care-sensitive health conditions that could be treated via access to public primary health care services.

Breast cancer screening program for risk groups: facts and perspectives.

to measure the frequency and compliance of breast cancer screening, according to the risk for this disease. a cross-sectional study with 950 female users of 38 public Primary Health Care services in São Paulo, between October and December 2013. According to UHS criteria, participants were grouped into high risk and standard risk, and frequency, association (p≤0.05), and screening compliance were measured. 6.7% had high risk and 93.3% standard risk, respectively; in these groups, the frequency and compliance of clinical breast examination were 40.3% and 37.1%, and 43.5% and 43.0% (frequency p=0.631, compliance p=0.290). Mammograms were 67.7% and 35.5% for participants at high risk, and 57.4% and 25.4% for those at standard risk (frequency p=0.090, compliance p=0.000). in the groups, attendance and conformity of the clinical breast exam were similar; for mammography, it was higher in those at high risk, with assertiveness lower than the 70% set in UHS.

Previous dry socket as a risk factor for alveolar osteitis: A nested case-control study in primary healthcare services.

BackgroundDry socket is one of the most common complications following tooth extraction, though no studies have been made on its main risk factors in the primary healthcare services of Barcelona (Spain). Objectives: To analyze the influence of different factors upon the appearance of dry socket in patients attended in the primary care setting, and to determine the possible presence of risk factors in patients who have suffered a previous episode of dry socket. Material and MethodsDuring 24 months, questionnaires were filled with data on the patients seen in different public primary healthcare services in the area of Barcelona (Spain). A case-control study was conducted to identify the main risk factors for developing complications in the form of dry socket. ResultsA mandibular location of the extracted tooth, poor oral hygiene, difficult extraction, and previous dry socket increased the risk of developing this complication. In patients with dry socket in the past, the risk of developing the same complication again, adjusted for difficulty of extraction, was seen to increase 11.45-fold (OR: 11.45; 95%CI: 1.06 to 123.74; p = 0.045). ConclusionsThe risk factors for dry socket are a mandibular location of the extracted tooth, poor oral hygiene, difficult extraction, and particularly a history of dry socket in the past. The identification of these factors the prevention of dry socket in each patient could be improved. Key words:Dry socket, risk factors, extraction, complications.

Assessment of the quality of Primary Health Care in Fortaleza, Brazil, from the perspective of adult service users in 2019.

Primary Health Care (PHC) is the "front door" and keystone of Brazil's public health system, meaning that the evaluation of the quality of primary care services is of utmost importance. Using the Primary Care Assessment Tool (PCAT), this study evaluated the performance of public PHC services in Fortaleza from the view of adult service users. We conducted a cross-sectional study of 233 adult service users from 19 primary care centers (PCCs) between June and December 2019, collecting data on the sociodemographic and epidemiological characteristics of users and structural features of PCCs. The association between user and PCC characteristics and primary care attribute scores was measured by multilevel logistic regression. Most participants were women, aged between 30 and 59 years, brown, house owners, had completed high school, did not own health insurance, and belonged to families with at least 4 members. The lowest and highest-scoring attributes were "first contact accessibility" and "first contact utilization" (2.8 and 8.1, respectively). The overall essential and general scores were 6.0 and 5.7, respectively. Having complete health teams, more community health workers, and a family and community medicine residency program had a positive effect on the general score (p<0.05). Overall, the public services analyzed in Fortaleza received a low performance rating from the adult service users.

Chikungunya virus ECSA lineage reintroduction in the northeasternmost region of Brazil

The Northeast region of Brazil registered the second-highest incidence proportion of Chikungunya fever in 2019. In that year, an outbreak consisting of patients presenting with febrile disease associated with joint pain was reported by the public primary health care service in the city of Natal, in the state of Rio Grande do Norte, in March 2019. At first, the aetiological agent of the disease was undetermined. Since much is still unknown about chikungunya virus' (CHIKV) genomic diversity and evolutionary history in this northeasternmost state, we used a combination of portable whole-genome sequencing, molecular clock, and epidemiological analyses that revealed the reintroduction of the CHIKV East-Central-South-African (ECSA) lineage into Rio Grande do Norte. We estimated that the CHIKV ECSA lineage was first introduced into Rio Grande do Norte in early June 2014, while the 2019 outbreak clade diverged around April 2018, during a period of increased Chikungunya incidence in the Southeast region, which might have acted as a source of virus dispersion towards the Northeast region. Together, these results confirm that the ECSA lineage continues to spread across the country through interregional importation events, likely mediated by human mobility.

Do depressive symptoms among pregnant women assisted in Primary Health Care services increase the risk of prematurity and low birth weight?

Objective:to investigate associations between depressive symptoms during pregnancy, low birth weight, and prematurity among women with low-risk pregnancies assisted in public Primary Health Care services.Method:prospective cohort with 193 pregnant women, using the Edinburgh Postnatal Depression Scale, telephone interviews, and medical records available in the health services. Associations of interest were obtained using the Cox regression model.Results:the participants were aged 24.9 years old (median) and had 11 years of schooling (median); 82.4% lived with their partners, and gestational age at the birth was 39 weeks (median). Twenty-five percent of the participants scored ≥13 on the Edinburgh scale. Depressive symptoms did not appear associated with low birth weight (RR=2.06; CI95%=0.56-7.61) or prematurity (RR=0.86; CI95%=0.24-3.09) in the adjusted analysis. However, premature labor increased the risk of low birth weight (RR=4.81; CI95%=1.01-23.0) and prematurity (RR=7.70; CI95%=2.50-23.7). Additionally, each week added to gestational age decreased the risk of low birth weight (RR=0.76; CI95%=0.61-0.95).Conclusion:the presence of depressive symptoms among women with low-risk pregnancies was not associated with low birth weight or prematurity.

Willingness to pay for primary health care at public facilities in the Western Cape Province, Cape Town, South Africa

Background and objectives As facilities are being prepared for the implementation of National Health Insurance (NHI) in South Africa, there is a pressing need to understand how the public equates the provision of health services at Primary Health Care (PHC) centres with monetary value. Accordingly, this exploratory study was designed to ascertain the willingness to pay (WTP) for public primary healthcare services in South Africa and to identify factors that influence the WTP. Methods The study was conducted in Cape Town, South Africa, among 453 persons presenting at two public primary health care centres, namely Bothasig Community Day Centre (CDC) and Goodwood CDC. The study used the contingent valuation range methodology. Descriptive statistics, multiple logistic and tobit regression analyses were conducted to assess demographics, socio-economic, and health access factors that influence WTP. Results Overall, 60% of participants were willing to pay for services offered at the PHC facilities. The average willingness to pay for all participants was 49.44 ZAR, with a median of 25 ZAR. The multiple logistic regression for grouped facilities showed unemployment, public transport, and the facility attended to be significant while public transport, facility visits, and facility attended were the only significant variables in the tobit model. There was less willingness to pay for those unemployed in comparison with students, those using public transport rather than walking, those frequenting the facilities more than first-time visitors and those attending Goodwood facility in comparison with Bothasig. Conclusion This study revealed factors related to the participants’ WTP and to their willingness to contribute towards the health service, though at very low amounts. Understanding the economic value placed upon a service provided in a facility is essential in decision-making for quality care improvements, especially as the South African health system is making the facilities ready for NHI.

Challenges in the care of patients with Chagas disease in the Brazilian public health system: A qualitative study with primary health care doctors.

BackgroundCare to patients with Chagas disease (CD) is still a challenge for health systems in endemic and non-endemic countries. In the Brazilian public health system, the expansion of Primary Health Care (PHC) services to remote and disadvantaged areas has facilitated the access of patients with CD to medical care, however this is in a context where care gaps remain, with insufficient public funding and inadequate distribution of services. Considering the need for studies on care to patients with CD in different settings, this study explored the challenges of family doctors to provide care to patients with CD in an endemic region in Brazil with high coverage of public PHC services.Methods and findingsThis is a qualitative study. A focus group with 15 family doctors was conducted in a municipality participating in a multicenter cohort that monitors almost two thousand patients with CD in an endemic region in Brazil. The data were analyzed using a thematic content analysis technique. The family doctors pointed out the following challenges for care to patients with CD: unsatisfactory medical training (academic education not suitable for the clinical management of the disease, and lack of training on CD in PHC); uncertainties regarding antiparasitic treatment in the chronic phase of the disease; difficulty in patients’ access to specialized care when necessary, especially to the cardiologist; and trivialization of the disease by patients as a barrier to seeking care.ConclusionThe access of CD patients to adequate medical care, even in regions with high coverage of public PHC services, still represents an important challenge for health systems. The results of this study may contribute to the development of strategies to improve the clinical management of CD in PHC.

Differentiating middle-aged long-term and short-term frequent attenders by means of the Northern Finland Birth Cohort 1966 Study.

Frequent attendance is largely a temporary phenomenon, but only few previous studies have made a distinction between long-term frequent attenders (FAs) and short-term FAs. The aim of this study is to compare the characteristics of middle-aged long-term FAs and short-term FAs. Data from a large Northern Finland Birth Cohort 1966 study's (NFBC1966) 46-year follow-up study (performed in 2012, N=10321) were used. The participants (n=4390) had used public primary healthcare (PPHC) services at least once during 2013-2016 according to Finnish national register data on outpatient visits. A FA was considered a patient who had used PPHC services ≥8 times during 1year. A long-term FA: a patient who was a FA in at least 3years during 2013-2016. A short-term FA: a patient who was a FA in 1 or 2years in 2013-2016. Cross-tabulation, Pearson's chi-squared test, Mann-Whitney U test, and univariate and multivariate binary logistic regression analyses were used. Of the 4390 participants, 132 (3.0%) were long-term FAs, 645 (14.7%) were short-term FAs, and 3613 (82.3%) were non-FAs. During 2013-2016, long-term FAs accounted for 34.8% of PPHC visits, while short-term FAs accounted 15.4%. Compared to short-term FAs, depression and high income (preventive attribute) were associated with long-term FAs. Female gender and managing usual activities were associated with short-term FAs. Poor self-reported health was associated with both long-term FAs and short-term FAs but increased the risk of being a long-term FA over three times compared to short-term FAs. Middle-aged long-term FAs and short-term FAs have distinct characteristics; namely, depression and high income differentiate long-term FAs from short-term FAs. Poor self-reported health was associated with long-term FAs in particular. In order to identify FAs with prolonged service needs and to develop far-reaching interventions, the focus of research should be on long-term FAs.

Access to dental services and oral health-related quality of life in the context of primary health care.

The aim of the present study was to evaluate the association between access to oral health care in the Primary Health Care (PHC) and Oral Health-Related Quality of Life (OHRQoL). The present study was a cross-sectional study, and the sample was composed of 412 users living in the areas covered by the public PHC services who visited a health unit for an oral exam or treatment in the last 24 months. Participants in the study responded to a home-based interview with questions that addressed socioeconomic status, behavioral, general health, dental prostheses, access to dental services in the PHC and their OHRQoL as measured by the Oral Health Impact Profile (OHIP-14) instrument. After the interview, a dental examination was performed to count the number of teeth. Chi-square tests, Student's t tests and multivariate analyses were performed using a hierarchical model and a Poisson regression with robust variance to evaluate the association between independent variables and OHRQoL. Access to oral health services in the PHC was statistically associated with OHRQoL, and the estimated prevalence rate was PR = 1.17 (CI 95% 1.00-1.37). In this study, the definition of access was based on the availability of dental consultations on demand. The study identified that lack of access to oral health services offered by the PHC was associated with a higher prevalence of impact on the quality of life of individuals.

Level of Satisfaction on Service Quality Dimensions Based on SERVQUAL Model Among Patients Attending 1 Malaysia Clinic in Kota Bharu, Malaysia

Implemented in 2010, 1 Malaysia Clinic (1MC) is the latest innovation in public primary healthcare services in Malaysia to serve the urban population. This study aimed to assess the level of satisfaction and its associated factors using the SERVQUAL (SERV-service, QUAL-quality) instrument. We also sought to compare the difference of mean score between expectation and perception of SERVQUAL dimension among patients attending 1MC in Kota Bharu district, Malaysia. This cross-sectional study included all nine 1MCs in the Kota Bharu district, Malaysia, and used the validated SERVQUAL questionnaire from Ministry of Health, Malaysia. The primary data was collected in January 2017. The sample size was proportionate to the average daily patient attendance for each clinic, and a simple random sampling method was applied to reduced selection bias. Satisfaction level was determined by the mean gap score of expectation and perception of the SERVQUAL dimension. A total of 386 patients were involved in this study (184 male and 202 female). Most were from the low socioeconomic group. Less than half of the patients were satisfied with the clinic services. The tangible dimension (service quality (SQ) gap: -0.25) was the most critical dimension among all five SQ dimensions assessed. The factors included low education level (adjusted odds ratio (adj. OR) 1.87; 95% confidence interval (CI): 1.06, 2.67; p = 0.024), monthly household income less than RM 3000 (adj. OR 2.97; 95% CI: 1.72, 5.51; p < 0.001), and frequency 3 3 visits (adj. OR 2.23; 95% CI: 1.44, 3.45; p < 0.001) had significant association with high level of satisfaction. 1MC has achieved its objective to increase the accessibility of health services among the low-income population in urban settings. However, most patients were not satisfied with certain parts of the services. Thus, proper evaluation of the service gap is required for improvement of the service.

Service intangibility and its implications for the work coordination of primary healthcare multi-professional teams in Brazil.

In certain service activities, the intangibility of what is being produced hinders the vision of an expected result or product. In multi-professional teams, this difficulty becomes increasingly greater, as participants' perceptions are conditioned to their respective fields of knowledge and different professional experiences. This is a common situation in healthcare services. To describe and explain the work coordination process applied by multi-professional teams in order to deal with the intangibility inherent in the healthcare services. This study involved six multi-professional teams from the public primary healthcare service in Brazil. Interviews and observations of team meetings were carried out, with focus on the critical elements of a coordination process: work plans and routines, roles and responsibilities, knowledge sharing, and a common reference history. There is coexistence of two distinct coordination processes being performed in the same work activity: operational coordination, associated with activities that somehow follow standard procedures; and diagnostic coordination, associated with diagnosis construction, alternatives analysis and decision making. The consequences of intangibility can be overcome by mechanisms that enable a common perspective among the participants involved in the productive process, and by the team members' familiarity with each other.

Health problems and the health care provider choices: A comparative study of urban and rural households in Egypt

ObjectiveTo assess families’ health problems and the health facility choices in an urban and a rural district in Egypt. MethodsA cross-sectional descriptive study with a multi-stage random sample of 948 urban and 401 rural households was undertaken in a district of Cairo and rural Giza. Data was collected through interviews. The questionnaire addressed health problems and the use of health services within the fortnight prior to the survey.A follow-up of a sub-sample of 285 urban and 114 rural households was carried out 2–3weeks after the first interview to assess the outcome of complaints. The EPi Info Statistical Package was used for analysis and comparing urban and rural families. ResultsOver 60% of urban and 78.8% of rural families had health complaints - respiratory, gastrointestinal and musculoskeletal. Outpatient clinics in public hospitals were the first choice for 49.7% of urban families and 23% of rural, while 25.7% of urban and 42.8% of rural families visited private clinics. Over half of the families with complaints recover from their illnesses within a fortnight. ConclusionUrban families have less health complaints than rural; however, rural families recover sooner. Families bypass often public primary health care services. Urban families overuse outpatient clinics in public hospitals.

Teaching at primary healthcare services within the Brazilian national health system (SUS) in Brazilian healthcare professionals' training

The aim of this study was to analyze the role of teaching at primary healthcare services within the Brazilian National Health System (SUS) in dentists' training, at a public university in the south of Brazil. A qualitative methodological approach (case study) was used. Interviews were conducted with 12 dentistry students, six dentists who were preceptors working in public primary healthcare services and three teachers connected with this curricular training. Our findings showed that the curricular training in SUS primary healthcare services had an impact on the dentists' education through establishment of bonds, autonomy in problem-solving and multiprofessional teamwork. It was seen that they learned about how healthcare services function, about healthcare and about development of cultural competence. There is a need to maintain constant questioning regarding these practices, and to ensure the presence of infrastructure and qualified professionals for teaching at these services.

Zinc in plasma and breast milk in adolescents and adults in pregnancy and pospartum: a cohort study in Uruguay.

To assess if age is a risk factor for low zinc nutritional status in pregnancy, postpartum and in breast milk concentration, and the association between mother zinc plasma level with zinc milk concentration. Cohort study comparing adolescents with adult women, with < 14 weeks of gestation at first prenatal care. Socio demographic and plasma zinc data were collected at that moment and at postpartum time (4 + 1 month). Milk zinc concentrations were also measured at 4 th month postpartum. Women were recruited from 16 public primary health care services in Uruguay Subjects: 151 adolescents and 161 adult women. Adolescent average plasma zinc at < 14 weeks of gestation was 84.4 ± 3.6 ug /dl and did not differ significantly from that for adult women (85.2 ± 13.6 ug/dl). Prevalence of hypozincemia was relatively low with but with no difference by age (14.6% in adolescents and 12.3% in adults). Zinc concentrations in breast milk were similar for adolescents, 1.24 mg. /L (CI 1.06 to 1.44) and adult women, 1.27 mg./L (CI .1.0-1.46). There was no correlation between plasma zinc and breast milk zinc concentrations in adults and a weak correlation in adolescents (- 0.27, P <0.05). Prevalence of hypozincemia in pregnancy was relatively low but similar in adolescents and adult women. Neither pregnancy nor age had negative consequences over postpartum plasma zinc, nor over breast milk zinc concentrations. No correlation was found between mother s plasma zinc and breast milk levels.

Foreword

This special issue of Memorias do Instituto Oswaldo Cruz focuses on leprosy (Hansen's disease or hanseniase in Portuguese). It is fitting that this issue is being published on the 100th anniversary of the death of Gerhard Henrik Armauer Hansen, the Norwegian physician who first identified the bacterium, Mycobacterium leprae, as the causative agent of this disease in 1873. Although Hansen's disease has been all but eliminated in this country, it is still a major health problem in many parts of the world. The latest statistics reported by the World Health Organization showed that worldwide new case detection was 228,474 in 2010. In Brazil, there were 34,894 new cases diagnosed, with 2,241 reported in children (6.4%), indicating that there are still areas where leprosy is clearly a health problem. Although it is true that Brazil remains one of the last remaining countries yet to reach the goal of less than one new case per 10,000 population, the degree to which the public primary health care service and Brazilian leprologists are working towards detecting and treating all cases is a testament to the strength of the program.

How much does it cost to achieve coverage targets for primary healthcare services? A costing model from Aceh, Indonesia

Despite significant investment in improving service infrastructure and training of staff, public primary healthcare services in low-income and middle-income countries tend to perform poorly in reaching coverage targets. One of the factors identified in Aceh, Indonesia was the lack of operational funds for service provision. The objective of this study was to develop a simple and transparent costing tool that enables health planners to calculate the unit costs of providing basic health services to estimate additional budgets required to deliver services in accordance with national targets. The tool was developed using a standard economic approach that linked the input activities to achieving six national priority programs at primary healthcare level: health promotion, sanitation and environment health, maternal and child health and family planning, nutrition, immunization and communicable diseases control, and treatment of common illness. Costing was focused on costs of delivery of the programs that need to be funded by local government budgets. The costing tool consisting of 16 linked Microsoft Excel worksheets was developed and tested in several districts enabled the calculation of the unit costs of delivering of the six national priority programs per coverage target of each program (such as unit costs of delivering of maternal and child health program per pregnant mother). This costing tool can be used by health planners to estimate additional money required to achieve a certain level of coverage of programs, and it can be adjusted for different costs and program delivery parameters in different settings.