The results suggest that improving the content of care during ANC visits may foster adequate use of ANC and encourage early initiation of ANC visits. Furthermore, health promotion programmes need to further encourage male involvement in pregnant women's decision to seek ANC to encourage adequate use of services.

BackgroundMathematical modelling has been a vital research tool for exploring complex systems, most recently to aid understanding of health system functioning and optimisation. System dynamics models (SDM) and agent-based models (ABM) are two popular complementary methods, used to simulate macro- and micro-level health system behaviour. This systematic review aims to collate, compare and summarise the application of both methods in this field and to identify common healthcare settings and problems that have been modelled using SDM and ABM.MethodsWe searched MEDLINE, EMBASE, Cochrane Library, MathSciNet, ACM Digital Library, HMIC, Econlit and Global Health databases to identify literature for this review. We described papers meeting the inclusion criteria using descriptive statistics and narrative synthesis, and made comparisons between the identified SDM and ABM literature.ResultsWe identified 28 papers using SDM methods and 11 papers using ABM methods, one of which used hybrid SDM-ABM to simulate health system behaviour. The majority of SDM, ABM and hybrid modelling papers simulated health systems based in high income countries. Emergency and acute care, and elderly care and long-term care services were the most frequently simulated health system settings, modelling the impact of health policies and interventions such as those targeting stretched and under resourced healthcare services, patient length of stay in healthcare facilities and undesirable patient outcomes.ConclusionsFuture work should now turn to modelling health systems in low- and middle-income countries to aid our understanding of health system functioning in these settings and allow stakeholders and researchers to assess the impact of policies or interventions before implementation. Hybrid modelling of health systems is still relatively novel but with increasing software developments and a growing demand to account for both complex system feedback and heterogeneous behaviour exhibited by those who access or deliver healthcare, we expect a boost in their use to model health systems.

BackgroundAcute human African trypanosomiasis (rHAT) caused by Trypanosoma brucei rhodesiense is associated with high mortality and is fatal if left untreated. Only a few studies have examined the psychological, social and economic impacts of rHAT. In this study, mixed qualitative and quantitative research methods were used to evaluate the socio-economic impacts of rHAT in Mambwe, Rufunsa, Mpika and Chama Districts of Zambia.MethodsIndividuals diagnosed with rHAT from 2004 to 2014 were traced using hospital records and discussions with communities. Either they, or their families, were interviewed using a structured questionnaire and focus group discussions were conducted with affected communities. The burden of the disease was investigated using disability adjusted life years (DALYs), with and without discounting and age-weighting. The impact of long-term disabilities on the rHAT burden was also investigated.ResultsSixty four cases were identified in the study. The majority were identified in second stage, and the mortality rate was high (12.5%). The total number of DALYs was 285 without discounting or age-weighting. When long-term disabilities were included this estimate increased by 50% to 462. The proportion of years lived with disability (YLD) increased from 6.4% to 37% of the undiscounted and un-age-weighted DALY total. When a more active surveillance method was applied in 2013–2014 the cases identified increased dramatically, suggesting a high level of under-reporting. Similarly, the proportion of females increased substantially, indicating that passive surveillance may be especially failing this group.An average of 4.9 months of productive time was lost per patient as a consequence of infection. The health consequences included pain, amnesia and physical disability. The social consequences included stigma, dropping out of education, loss of friends and self-esteem. Results obtained from focus group discussions revealed misconceptions among community members which could be attributed to lack of knowledge about rHAT.ConclusionsThe social and economic impact of rHAT on rural households and communities is substantial. Improved surveillance and strengthening of local medical services are needed for early and accurate diagnosis. Disease prevention should be prioritised in communities at risk of rHAT, and interventions put in place to prevent zoonotic disease spill over from domestic animals and wildlife. Supportive measures to mitigate the long-term effects of disability due to rHAT are needed.Electronic supplementary materialThe online version of this article (10.1186/s40249-017-0363-6) contains supplementary material, which is available to authorized users.

BackgroundImproving maternal health outcomes by reducing barriers to accessing maternal health services is a key goal for most developing countries. This paper analyses the effect of user fee removal, which was announced for rural areas of Zambia in April 2006, on the use of public health facilities for childbirth.MethodsData from the 2007 Zambia Demographic and Health Survey, including birth histories for the five years preceding the survey, is linked to administrative data and geo-referenced health facility census data. We exploit a difference-in-differences design, due to a differential change in user fees at the district level; fees were removed in 54 rural districts, but not in the 18 remaining urban districts. We use multilevel modelling to estimate the effect of this policy change, based on 4018 births from May 2002 to September 2007, covering a period before and after the policy announcement in April 2006.ResultsThe difference-in-difference estimates point to statistically insignificant changes in the proportion of women giving birth at home and in public facilities, but significant changes are found for deliveries in private (faith-based) facilities. Thus, the abolition of delivery fees is found to have some effect on where Zambian mothers choose to have their children born.ConclusionThe removal of user fees has not overcome barriers to the utilisation of delivery services at public facilities. User fee removal may also yield unintended consequences deterring the utilisation of delivery services. Therefore, abolishing user fees, alone, may not be sufficient to affect changes in utilisation; instead, other efforts, such as improving service quality, may have a greater impact.

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