Household strategies to cope with the economic costs of illness

Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China

BACKGROUND

Tuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden.

METHODS

Using a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding.

RESULTS

Patients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable.

CONCLUSIONS

Financial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.

A Study of Out-of-pocket Health Expenditures

The aim of this study is to analyze health care expenditures in seven South Asian countries, namely, India, Pakistan, Sri Lanka, Maldives, Bhutan, Bangladesh and Nepal. The data are taken for 19 years from 1995 to 2013. We specifically examine the out-of-pocket health care expenditure in these countries. Per capita health expenditure differences have been compared. We also develop regression model for out-of-pocket expenditure with the factors affecting it, that is, per capita health expenditure, household final consumption expenditure and public health expenditure. Logarithm values of out-of-pocket expenditure have also been used to develop a separate log model for the same. The results suggest that Maldives has the highest per capita health expenditure, while out-of-pocket health expenditure as a percentage of total expenditure on health is the highest for India. The key determinant of out-of-pocket expenditures is the final household expenditures as the percentage of GDP.

Beyond pills and tests: addressing the social determinants of tuberculosis

Poverty drives tuberculosis (TB) rates but the approach to TB control has been disproportionately biomedical. In 2015, the World Health Organization's End TB Strategy explicitly identified the need to address the social determinants of TB through socio-economic interventions. However, evidence concerning poverty reduction and cost mitigation strategies is limited. The research described in this article, based on the 2016 Royal College of Physicians Linacre Lecture, aimed to address this knowledge gap. The research was divided into two phases: the first phase was an analysis of a cohort study identifying TB-related costs of TB-affected households and creating a clinically relevant threshold above which those costs became catastrophic; the second was the design, implementation and evaluation of a household randomised controlled evaluation of socio-economic support to improve access to preventive therapy, increase TB cure, and mitigate the effects of catastrophic costs. The first phase showed TB remains a disease of people living in poverty - 'free' TB care was unaffordable for impoverished TB-affected households and incurring catastrophic costs was associated with as many adverse TB treatment outcomes (including death, failure of treatment, lost to follow-up and TB recurrence) as multidrug resistant (MDR) TB. The second phase showed that, in TB-affected households receiving socio-economic support, household contacts were more likely to start and adhere to TB preventive therapy, TB patients were more likely to be cured and households were less likely to incur catastrophic costs. In impoverished Peruvian shantytowns, poverty remains inextricably linked with TB and incurring catastrophic costs predicted adverse TB treatment outcome. A novel socio-economic support intervention increased TB preventive therapy uptake, improved TB treatment success and reduced catastrophic costs. The impact of the intervention on TB control is currently being evaluated by the Community Randomized Evaluation of a Socio-economic Intervention to Prevent TB (CRESIPT) study.

Parental health shocks and schooling: The impact of mutual health insurance in Rwanda

The goal of this study was to look at the educational spill-over effects of health insurance on schooling with a focus on the Rwandan Community Based Health Insurance Programme, the Mutual Health Insurance scheme. Using a two-person general equilibrium overlapping generations model, this paper theoretically analyses the possible effect of health insurance on the relationship between parental health shocks and child schooling. Individuals choose whether or not they want to incur a medical cost by seeking care in order to reduce the effect of health shocks on their labour market availability and productivity. The theoretical results show that, health shocks negatively affect schooling irrespective of insurance status. However, if the health shock is severe (incapacitating) or sudden in nature, there is a discernible mitigating effect of health insurance on the negative impact of parental ill health on child schooling. The results are tested empirically using secondary data from the third Integrated Household Living Conditions Survey (EICV) for Rwanda, collected in 2011. A total of 2401 children between the ages of 13 and 18 are used for the analysis. This age group is selected due to the age of compulsory education in Rwanda. Based on average treatment effect on treated we find a statistically significant difference in attendance between children with MHI affiliated parents and those with uninsured parents of about 0.044. The negative effect of a father being severely ill is significant only for uninsured household. For the case of the mother, this effect is felt by female children with uninsured parents only when the illness is sudden. The observed effects are more pronounced for older children. While the father's ill health (sever or sudden) significantly and negatively affects their working hours, health insurance plays appears to increase their working hours. The effects of health insurance extend beyond health outcomes.

Cost of illness for outpatients attending public and private hospitals in Bangladesh

BACKGROUND

A central aim of Universal Health Coverage (UHC) is protection for all against the cost of illness. In a low income country like Bangladesh the cost burden of health care in tertiary facilities is likely to be significant for most citizens. This cost of an episode of illness is a relatively unexplored policy issue in Bangladesh. The objective of this study was to estimate an outpatient's total cost of illness as result of treatment in private and public hospitals in Sylhet, Bangladesh.

METHODS

The study used face to face interviews at three hospitals (one public and two private) to elicit cost data from presenting outpatients. Other socio-economic and demographic data was also collected. A sample of 252 outpatients were randomly selected and interviewed. The total cost of outpatients comprises direct medical costs, non-medical costs and the indirect costs of patients and caregivers. Indirect costs comprise travel and waiting times and income losses associated with treatment.

RESULTS

The costs of illness are significant for many of Bangladesh citizens. The direct costs are relatively minor compared to the large indirect cost burden that illness places on households. These indirect costs are mainly the result of time off work and foregone wages. Private hospital patients have higher average direct costs than public hospital patients. However, average indirect costs are higher for public hospital patients than private hospital patients by a factor of almost two. Total costs of outpatients are higher in public hospitals compared to private hospitals regardless of patient's income, gender, age or illness.

CONCLUSION

Overall, public hospital patients, who tend to be the poorest, bear a larger economic burden of illness and treatment than relatively wealthier private hospital patients. The large economic impacts of illness need a public policy response which at a minimum should include a national health insurance scheme as a matter of urgency.

Health Issues and Challenges among Indian Urban Poor

In the last 60 years since independence, India had achieved considerable improvements in the health of its population as reflected in their life expectancies which have doubled within this period. This article aims at explaining pertinent health-care issues and challenges based on some health indicators in India by using the literature review method that involved collection of material from the online sources, which included government documents, articles and publications related to healthcare, healthcare indicators, poverty, financial burden and coping strategies. To avoid premature deaths among adults, children and maternal mortalities, greater attention should be given to prevention and treatment of non-communicable diseases, and women and other social determinants of health. More attention should also be given to the reduction of births among teenage girls in order to avoid premature morbidity and mortality. To protect the vulnerable and poor, the government should provide more resources since financial burden of curative care is higher among lower income groups. However, in poorer states, the government tends to have relatively low ability to raise their own resources and the people in these states have a lower ability to pay for private insurance. Therefore, it is worthwhile and pertinent that the government initiates social insurance.

Can Households Cope with Health Shocks in Vietnam?

This paper investigates the economic impact of health shocks on working-age adults in Vietnam during 2004-2008, using a fixed effects specification. Health shocks cover disability and morbidity and are measured by 'days unable to carry out regular activity', 'days in bed due to illness/injury', and 'hospitalization'. Overall, Vietnamese households are able to smooth total non-health expenditures in the short run in the face of a significant rise in out-of-pocket health expenditures. However, this is accomplished through vulnerability-enhancing mechanisms, especially in rural areas, including increased loans and asset sales and decreased education expenditures. Female-headed and rural households are found to be the least able to protect consumption. Results highlight the need to extend and deepen social protection and universal health coverage. © 2015 The Authors. Health Economics published by John Wiley & Sons Ltd.

Coping with the economic burden of Diabetes, TB and co-prevalence: evidence from Bishkek, Kyrgyzstan

Background

The increasing number of patients co-affected with Diabetes and TB may place individuals with low socio-economic status at particular risk of persistent poverty. Kyrgyz health sector reforms aim at reducing this burden, with the provision of essential health services free at the point of use through a State-Guaranteed Benefit Package (SGBP). However, despite a declining trend in out-of-pocket expenditure, there is still a considerable funding gap in the SGBP. Using data from Bishkek, Kyrgyzstan, this study aims to explore how households cope with the economic burden of Diabetes, TB and co-prevalence.

Methods

This study uses cross-sectional data collected in 2010 from Diabetes and TB patients in Bishkek, Kyrgyzstan. Quantitative questionnaires were administered to 309 individuals capturing information on patients’ socioeconomic status and a range of coping strategies. Coarsened exact matching (CEM) is used to generate socio-economically balanced patient groups. Descriptive statistics and logistic regression are used for data analysis.

Results

TB patients are much younger than Diabetes and co-affected patients. Old age affects not only the health of the patients, but also the patient’s socio-economic context. TB patients are more likely to be employed and to have higher incomes while Diabetes patients are more likely to be retired. Co-affected patients, despite being in the same age group as Diabetes patients, are less likely to receive pensions but often earn income in informal arrangements. Out-of-pocket (OOP) payments are higher for Diabetes care than for TB care. Diabetes patients cope with the economic burden by using social welfare support. TB patients are most often in a position to draw on income or savings. Co-affected patients are less likely to receive social welfare support than Diabetes patients. Catastrophic health spending is more likely in Diabetes and co-affected patients than in TB patients.

Conclusions

This study shows that while OOP are moderate for TB affected patients, there are severe consequences for Diabetes affected patients. As a result of the underfunding of the SGBP, Diabetes and co-affected patients are challenged by OOP. Especially those who belong to lower socio-economic groups are challenged in coping with the economic burden.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1369-7) contains supplementary material, which is available to authorized users.

Economic costs of fever to households in the middle belt of Ghana

Background

Malaria is one of the main health problems in the sub-Saharan Africa accounting for approximately 198 million morbidity and close to 600,000 mortality cases. Households incur out-of-pocket expenditure for treatment and lose income as a result of not being able to work or care for family members. The main objective of this survey was to assess the economic cost of treating malaria and/or fever with the new ACT to households in the Kintampo districts of Ghana where a health and demographic surveillance systems (KHDSS) are set up to document population dynamics.

Methods

The study was a cross-sectional survey conducted from October 2009 to July 2011 using community members’ accessed using KHDSS population in the Kintampo area. An estimated sample size of 4226 was randomly selected from the active members of the KHDSS. A structured questionnaire was administered to the selected populates who reported of fever within the last 2 weeks prior to the visit. Data was collected on treatment-seeking behaviour, direct and indirect costs of malaria from the patient perspective.

Results

Of the 4226 households selected, 947 households with 1222 household members had fever out of which 92 % sought treatment outside home; 55 % of these were females. 31.6 % of these patients sought care from chemical shops. A mean amount of GHS 4.2 (US$2.76) and GHS 18.0 (US$11.84) were incurred by households as direct and indirect cost respectively. On average a household incurred a total cost of GHS 22.2 (US$14.61) per patient per episode. Total economic cost was lowest for those in the highest quintile and highest for those in the middle quintile.

Conclusion

The total cost of treating fever/malaria episode is relatively high in the study area considering the poverty levels in Ghana. The NHIS has positively influenced health-seeking behaviours and reduced the financial burden of seeking care for those that are insured.

Methodological Issues to Consider When Collecting Data to Estimate Poverty Impact in Economic Evaluations in Low-income and Middle-income Countries

Out-of-pocket spending is increasingly recognized as an important barrier to accessing health care, particularly in low-income and middle-income countries (LMICs) where a large portion of health expenditure comes from out-of-pocket payments. Emerging universal healthcare policies prioritize reduction of poverty impact such as catastrophic and impoverishing healthcare expenditure. Poverty impact is therefore increasingly evaluated alongside and within economic evaluations to estimate the impact of specific health interventions on poverty. However, data collection for these metrics can be challenging in intervention-based contexts in LMICs because of study design and practical limitations. Using a set of case studies, this letter identifies methodological challenges in collecting patient cost data in LMIC contexts. These components are presented in a framework to encourage researchers to consider the implications of differing approaches in data collection and to report their approach in a standardized and transparent way.

Inequity in costs of seeking sexual and reproductive health services in India and Kenya

Objective

This study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending.

Methods

Data for this study were collected as a part of the situational analysis for the “Diagonal Interventions to Fast Forward Enhanced Reproductive Health” (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income.

Results

The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03–7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were “receiving [money] from partner or household members” (69 %) and “using own savings or regular income” (44 %), respectively.

Conclusion

Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.

Economic Burden of HIV/AIDS Upon Households in Nepal: A Critical Review

Thousands of people are infected with HIV/AIDS in Nepal and most of them are adults of working age. Therefore, HIV/AIDS is a big burden in Nepal. This review was conducted to find the existing knowledge gap about the economic burden of HIV/AIDS at the household level in Nepal, the extent of economic burden exerted by the disease, and to provide policy recommendations. It is concluded that there was a considerable knowledge gap about the issue, and the economic burden exerted by HIV/AIDS was big enough to push the affected households into poverty. It is suggested that more studies need to be conducted to fill the knowledge gap. Similarly, Government of Nepal and other organisations working in the field of HIV/AIDS need to provide economic supports (e.g.- support for travel costs) to the HIV positive people and need to increase the awareness level among general population for reducing stigma and discrimination, and reducing economic burden on them.

Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti: A pilot study

BACKGROUND

Women in low- and middle-income countries account for 51% of breast cancer cases globally. These patients often delay seeking care and, therefore, present with advanced disease, partly because of fear of catastrophic health care expenses. Although there have been efforts to make health care affordable in low- and middle-income countries, the financial burden of out-of-pocket (OOP) expenses for nonmedical costs, such as transportation and lost wages, often is overlooked.

METHODS

An institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante for this cross-sectional study. In total, 61 patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were selected via convenience sampling. They were interviewed between March and May 2014 to quantify the expenses they incurred during the course of diagnosis and treatment. These expenses included medical costs at outside facilities, as well as nonmedical costs (eg, transportation, meals, etc).

RESULTS

The median, nonmedical OOP expenses incurred by breast cancer patients at HUM were $233 (95% confidence interval [95% CI] $170-304) for diagnostic visits, $259 (95% CI $200-533) for chemotherapy visits, and $38 (95% CI $23-140) for surgery visits. The median total OOP expense (including medical costs) was $717 (95% CI $619-1,171). To pay for these expenses, 52% of participants stated that they went into debt; however, the amount of debt was not quantified. The median income of these patients was $1,333 (95% CI $778-2,640), and the median sum of OOP expenses and lost wages was $2,996 (95% CI $1,676-5,179).

CONCLUSION

Despite receiving free care: at HUM, more than two-thirds of participants met conservative criteria for catastrophic medical expenses (defined as spending more than 40% of their potential household income on OOP payments). Further studies are needed to understand the magnitude of OOP health care expenses for the poor worldwide, how to aid them during their treatment program, and its impact on their health outcomes.

Understanding Interpretations of and Responses to Childhood Fever in the Chikhwawa District of Malawi

Background

Universal access to, and community uptake of malaria prevention and treatment strategies are critical to achieving current targets for malaria reduction. Each step in the treatment-seeking pathway must be considered in order to establish where opportunities for successful engagement and treatment occur. We describe local classifications of childhood febrile illnesses, present an overview of treatment-seeking, beginning with recognition of illness, and suggest how interventions could be used to target the barriers experienced.

Methods

Qualitative data were collected between September 2010 and February 2011. A total of 12 Focus Group Discussions and 22 Critical Incident Interviews were conducted with primary caregivers who had reported a recent febrile episode for one of their children.

Findings and Conclusion

The phrase ‘kutentha thupi’, or ‘hot body’ was used to describe fever, the most frequently mentioned causes of which were malungo (translated as ‘malaria’), mauka, nyankhwa and (m)tsempho. Differentiating the cause was challenging because these illnesses were described as having many similar non-specific symptoms, despite considerable differences in the perceived mechanisms of illness. Malungo was widely understood to be caused by mosquitoes. Commonly described symptoms included: fever, weakness, vomiting, diarrhoea and coughing. These symptoms matched well with the biomedical definition of malaria, although they also overlapped with symptoms of other illnesses in both the biomedical model and local illness classifications. In addition, malungo was used interchangeably to describe malaria and fever in general. Caregivers engaged in a three-phased approach to treatment seeking. Phase 1—Assessment; Phase 2—Seeking care outside the home; Phase 3—Evaluation of treatment response. Within this paper, the three-phased approach is explored to identify potential interventions to target barriers to appropriate treatment. Community engagement and health promotion, the provision of antimalarials at community level and better training health workers in the causes and treatment of non-malarial febrile illnesses may improve access to appropriate treatment and outcomes.

Household coping strategies for delivery and related healthcare cost: findings from rural Bangladesh

OBJECTIVES

This study aims to measure the economic costs of maternal complication and to understand household coping strategies for financing maternal healthcare cost.

METHODS

A household survey of the 706 women with maternal complication, of whom 483 had normal delivery, was conducted to collect data at 6 weeks and 6 months post-partum. Data were collected on socio-economic information of the household, expenditure during delivery and post-partum, coping strategies adopted by households and other related information.

RESULTS

Despite the high cost of health care associated with maternal complications, the majority of families were capable of protecting consumption on non-health items. Around one-third of households spent more than 20% of their annual household expenditure on maternal health care. Almost 50% were able to avoid catastrophic spending because of the coping strategies that they relied on. In general, households appeared resilient to short-term economic consequences of maternal health shocks, due to the availability of informal credit, donations from relatives and selling assets. While richer households fund a greater portion of the cost of maternal health care from income and savings, the poorer households with severe maternal complication resorted to borrowing from local moneylenders at high interest, which may leave them vulnerable to financial difficulties.

CONCLUSION

Financial protection, especially for the poor, may benefit households against economic consequences of maternal complication.

Economic consequences of ill-health for households in northern rural India

BACKGROUND

As compared to other countries in South East Asia, India's health care system is characterized by very high out of pocket payments, and consequently low financial protection and access to care. This paper describes the relative importance of ill-health compared to other adverse events, the conduits through which ill-health affects household welfare and the coping strategies used to finance these expenses.

METHODS

Cross-sectional data are used from a survey conducted with 5241 households in Uttar Pradesh and Bihar in 2010 that included a household shocks module and detailed information about health care use and spending.

RESULTS

Health-related adverse events were the second most common adverse events (34%), after natural disasters (51%). Crop and livestock disease and weddings each affected about 8% of households. Only a fourth of households reported to have recovered from illness and/or death in the family (by the time of the survey). Most of the households' economic burden related to ill-health was depending on direct medical costs, but indirect costs (such as lost earnings and transportation or food costs) were also not negligible. Close to half of the health expenditures were made for chronic conditions. Households tried to cope with health-related expenditures mostly by dissaving, borrowing and selling assets. Few households reported having to reduce (food) consumption in response to ill-health.

CONCLUSIONS

In the absence of pre-financing schemes, ill-health events pose a substantial threat to household welfare in rural India. While most households seem to be able to smooth consumption in the short term, coping strategies like selling assets and borrowing from moneylenders are likely to have severe long term consequences. As most of the households' economic risk related to ill-health appears to depend on out of pocket spending, introducing health insurance may contribute significantly to alleviate economic hardship for families in rural India. The importance of care for chronic diseases, however, represents a big challenge for the sustainability of community based health insurance schemes, since it is necessary to ensure a sufficient degree of risk pooling.

The economic impact of the insured patients with severe chronic and acute illnesses: a qualitative approach

Background

Little research has focused on the economic hardship among the insured with severe illnesses and high treatment costs, in particular, the consequence of poorer insurance coverage for high-cost illnesses. Therefore, we presented the case for identifying the experiences of insured patients with severe chronic and acute illnesses. This study identified a qualitative understanding of the economic impact of severe chronic and acute illnesses and household strategies to deal with high treatment costs.

Design

Interviews were conducted with 19 insured households of three different health insurance programs with a family member that had been hospitalized for severe chronic or acute illnesses in either Banyumas or Margono Sukarjo hospitals in Banyumas, Central Java, Indonesia. A thematic analysis was applied to guide the interpretation of the data.

Results

Insured households with a family member that had been hospitalized for severe chronic and acute illnesses were greatly affected by the high treatment costs. Four major issues emerged from this qualitative study: insured patients are still burdened with high out-of-pocket payments, households adopt various strategies to cope with the high cost of treatments, households experience financial hardships, and positive and negative perceptions of the insured regarding their health insurance coverage for acute and chronic illnesses.

Conclusions

Askes and Jamsostek patients faced financial burdens from high cost sharing for hospital amenities, non-covered drugs, and treatments and other indirect costs. Meanwhile, Jamkesmas beneficiaries faced no financial burden for related medical services but were rather burdened with indirect costs for the carers. Households relied on internal resources to cover hospital bills as the first strategy, which included the mobilization of savings, sale of assets, and borrowing of money. External support was tapped secondarily and included financial support from extended family members, donations from neighbors and the community, and additional benefits from employers. However, insured households overall had positive perceptions of insurance.

Is there a need to mitigate the social and financial consequences of tuberculosis at the individual and household level?

This paper reviews evidence on social and economic costs of tuberculosis. Key socio-economic consequences include stigma, social isolation, increased out-of-pocket expenditures for medical and non-medical costs and reduced income. Many of the financing methods that households use have long-term negative impacts and the poor are most vulnerable to these costs. Together, these negative consequences adversely affect TB control, in terms of delayed diagnosis, delayed initiation of treatment, suboptimal adherence and failure to complete treatment, as well as the coping and well being of the individual and household. There are two ways to reduce treatment costs for the patient; one can either reduce the direct and indirect costs of seeking a diagnosis and obtaining treatment and/or provide income transfers to offset some of those costs incurred. Social transfers in the form of food, cash or vouchers can mitigate the negative effects by enabling the individual to seek a diagnosis, protecting minimum food expenditures, reducing the need to accumulate debt and reduce productive assets and reducing the negative impacts on other household members, particularly young children and school-age children.

Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru

BACKGROUND

Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB-affected households) may worsen poverty and health. Extreme TB-associated costs have been termed "catastrophic" but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs.

METHODS AND FINDINGS

From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2-4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%-43%) in the least-poor houses versus 48% (95% CI = 36%-50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs ≥20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%-61%] versus 38% [95% CI = 34%-41%], p<0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7-15], p<0.001), previous TB (OR = 2.1 [95% CI = 1.3-3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00-1.01], p = 0.02), and catastrophic costs (OR = 1.7 [95% CI = 1.1-2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%-28%), similar to that of MDR TB (20% [95% CI = 14%-25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥10% or ≥15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain "dis-saving" variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients.

CONCLUSIONS

Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease. Please see later in the article for the Editors' Summary.

Distressed financing of household out-of-pocket health care payments in India: incidence and correlates

Out-of-pocket (OOP) health care payments financed through borrowings or sale of household assets are referred to as distressed health care financing. This article expands this concept (to include contributions from friends or relatives) and examines the incidence and correlates of distressed health care financing in India. The analysis finds a decisive influence of distressed financing in India as over 60 and 40% of hospitalization cases from rural and urban areas, respectively, report use of such coping strategies. Altogether, sources such as borrowings, sale of household assets and contributions from friends and relatives account for 58 and 42% share in total OOP payments for inpatient care in rural and urban India, respectively. Further, the results show significant socioeconomic gradient in the distribution of distressed financing with huge disadvantages for marginalized sections, particularly females, elderly and backward social groups. Multivariate logistic regression informs that households are at an elevated risk of indebtedness while seeking treatment for non-communicable diseases, particularly cancer. Evidence based on intersectional framework reveals that, despite similar socioeconomic background, males are more likely to use borrowings for health care financing than females. In conclusion, the need for social protection policies and improved health care coverage is emphasized to curtail the incidence of distressed health care financing in India.

Decision-making on intra-household allocation of bed nets in Uganda: do households prioritize the most vulnerable members?

Background

Access to insecticide-treated bed nets has increased substantially in recent years, but ownership and use remain well below 100% in many malaria endemic areas. Understanding decision-making around net allocation in households with too few nets is essential to ensuring protection of the most vulnerable. This study explores household net allocation preferences and practices across four districts in Uganda.

Methods

Data collection consisted of eight focus group discussions, twelve in-depth interviews, and a structured questionnaire to inventory 107 sleeping spaces in 28 households.

Results

In focus group discussions and in-depth interviews, participants almost unanimously stated that pregnant women, infants, and young children should be prioritized when allocating nets. However, sleeping space surveys reveal that heads of household sometimes receive priority over children less than five years of age when households have too few nets to cover all members.

Conclusions

When asked directly, most net owners highlight the importance of allocating nets to the most biologically vulnerable household members. This is consistent with malaria behaviour change and health education messages. In actual allocation, however, factors other than biological vulnerability may influence who does and does not receive a net.

Out-of-pocket payments, health care access and utilisation in south-eastern Nigeria: a gender perspective

Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by using a combination of quantitative and qualitative analysis to investigate the gendered impact of OOPs on healthcare utilisation in south-eastern Nigeria. 411 households were surveyed and six single-sex Focus Group Discussions conducted. This study confirmed the socioeconomic and demographic vulnerability of female-headed households (FHHs), which contributed to gender-based inter-household differences in healthcare access, cost burden, choices of healthcare providers, methods of funding healthcare and coping strategies. FHHs had higher cost burdens from seeking care and untreated morbidity than male-headed households (MHHs) with affordability as a reason for not seeking care. There is also a high utilisation of patent medicine vendors (PMVs) by both households (PMVs are drug vendors that are unregulated, likely to offer very low-quality treatment and do not have trained personnel). OOP payment was predominantly the means of healthcare payment for both households, and households spoke of the difficulties associated with repaying health-related debt with implications for the medical poverty trap. It is recommended that the removal of user fees, introduction of prepayment schemes, and regulating PMVs be considered to improve access and provide protection against debt for FHHs and MHHs. The vulnerability of widows is of special concern and efforts to improve their healthcare access and broader efforts to empower should be encouraged for them and other poor households.

Provider payment methods and health worker motivation in community-based health insurance: a mixed-methods study

In a community-based health insurance (CBHI) introduced in 2004 in Nouna health district, Burkina Faso, poor perceived quality of care by CBHI enrollees has been a key factor in observed high drop-out rates. The poor quality perceptions have been previously attributed to health worker dissatisfaction with the provider payment method used by the scheme and the resulting financial risk of health centers. This study applied a mixed-methods approach to investigate how health workers working in facilities contracted by the CBHI view the methods of provider payment used by the CBHI. In order to analyze these relationships, we conducted 23 in-depth interviews and a quantitative survey with 98 health workers working in the CBHI intervention zone. The qualitative in-depth interviews identified that insufficient levels of capitation payments, the infrequent schedule of capitation payment, and lack of a payment mechanism for reimbursing service fees were perceived as significant sources of health worker dissatisfaction and loss of work-related motivation. Combining qualitative interview and quantitative survey data in a mixed-methods analysis, this study identified that the declining quality of care due to the CBHI provider payment method was a source of significant professional stress and role strain for health workers. Health workers felt that the following five changes due to the provider payment methods introduced by the CBHI impeded their ability to fulfill professional roles and responsibilities: (i) increased financial volatility of health facilities, (ii) dissatisfaction with eligible costs to be covered by capitation; (iii) increased pharmacy stock-outs; (iv) limited financial and material support from the CBHI; and (v) the lack of mechanisms to increase provider motivation to support the CBHI. To address these challenges and improve CBHI uptake and health outcomes in the targeted populations, the health care financing and delivery model in the study zone should be reformed. We discuss concrete options for reform based on the study findings.

Does health insurance improve health?: Evidence from a randomized community-based insurance rollout in rural Burkina Faso

From 2004 to 2006, a community-based health insurance (CBI) scheme was rolled out in Nouna District, Burkina Faso, with the objective of improving access to health services and population health. We explore the random timing of the insurance rollout generated by the stepped wedge cluster-randomized design to evaluate the welfare and health impact of the insurance program. Our results suggest that the insurance had limited effects on average out-of-pocket expenditures in the target areas, but substantially reduced the likelihood of catastrophic health expenditure. The introduction of the insurance scheme did not have any effect on health outcomes for children and young adults, but appears to have increased mortality among individuals aged 65 and older. The negative health effects of the program appear to be primarily driven by the adverse provider incentives generated by the scheme and the resulting decline in the quality of care received by patients.

The inability to pay for health services in Central and Eastern Europe: evidence from six countries

BACKGROUND

Out-of-pocket payments for health services constitute a major financial burden for patients in Central and Eastern European (CEE) countries. Individuals who are unable to pay use different coping strategies (e.g. borrowing money or foregoing service utilization), which can have negative consequences on their health and social welfare. This article explores patients' inability to pay for outpatient and hospital services in six CEE countries: Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine.

METHODS

The analysis is based on quantitative data collected in 2010 in nationally representative surveys. Two indicators of inability to pay were considered: the need to borrow money or sell assets and foregoing service utilization. Statistical analyses were applied to investigate associations between the indicators of inability to pay and individual characteristics.

RESULTS

Patient payments are most common in Bulgaria, Ukraine, Romania and Lithuania and often include informal payments. Romanian and, particularly, Ukrainian patients most often face difficulties to pay for health services (with approximately 40% of Ukrainian payers borrowing money or selling assets to cover hospital payments and approximately 60% of respondents who need care foregoing services). Inability to pay mainly affects those with poor health and low incomes.

CONCLUSION

Widespread patient payments constitute a major financial barrier to health service use in CEE. There is a need to formalize them where they are informal and to take measures to protect vulnerable population groups, especially those with limited possibilities to deal with payment difficulties.

Effects of household composition and income security on body weight in working-age men

OBJECTIVE

Many recent studies have provided evidence suggesting that increases in body weight may spread via social networks. The mechanism(s) by which this might occur have become the subject of much speculation, but to date little direct evidence has been available. Building on evidence from economics, anthropology, and behavioral biology, within-household peers might influence body weight via implicit provision of income security was hypothesized.

DESIGN AND METHODS

Using a sample of 2,541 working-age men from the National Longitudinal Survey of Youth (1979), the effect of cohabitation on weight gain over a 6-year period was estimated. The potential confound caused by the joint determination of economic insecurity and cohabitation status with instrumental variables that exploit variation in local and state-level macroeconomic conditions and the presence of children in the home was addressed.

RESULTS

The marginal effect of cohabitation with adults on body weight is negative. Moreover, the magnitude of the effect is more than six times greater when the cohabitant is engaged in paid employment.

CONCLUSIONS

Income insecurity may play an important role in peer-to-peer transmission of weight gain.

Health Expenditure and Impoverishment in India

This article examines impoverishment effect of the out-of-pocket (OOP) payment for health care on households in India where only 10 per cent of the population is covered by insurance. At the national level, 10.1 per cent of rural households as against 6.2 per cent of urban households have either become poor or poorer as a consequence of OOP for health care. The proportion of rural impoverished households due to OOP health expenditure in the four most underdeveloped states of Orissa, Bihar, Uttar Pradesh and Madhya Pradesh are 11.4, 9.5, 7.9 and 7.3 per cents, respectively. The corresponding proportion of urban impoverished households for these states are 7.2, 7.5, 5.9 and 5.1 per cents, respectively. It is also found that the OOP payment tends to increase significantly with inequality in income distribution and shortage of physicians at the state level. Health system inadequacy measure by population density per physician has escalating effect on impoverishment.

The economic burden of chronic disease care faced by households in Ukraine: a cross-sectional matching study of angina patients

Introduction

Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, and their prevalence in lower- and middle-income countries (LMIC) is on the rise. The burden of chronic health expenditure born by patient households in these countries may be very high, particularly where out-of-pocket payments for health care are common. One such country where out-of-pocket payments are especially high is Ukraine. The financial impact of NCDs on households in this country has not been researched.

Methods

We set out to explore the burden of NCD care in Ukraine with a study of angina patients. Using data from the Ukraine World Health Survey of 2003 we employed the novel Coarsened Exact Matching approach to estimate the difference in out-of-pocket payment (OPP) for health care between households with a stable angina pectoris (a chronic form of IHD) patient and those without. The likelihood of engaging in catastrophic spending and using various distress financing mechanisms (e.g. sale of assets, borrowing) among angina households compared with non-angina households was also explored.

Results

Among angina patient households (n = 203), OPP occupied an average of 32% of household effective income. After matching, angina households experienced significantly higher monthly per capita OPP for health care (B = $2.84) and medicines (B = $2.94), but were not at significantly higher odds of engaging in catastrophic spending. Odds of engaging in ‘sale of assets’ (OR = 2.71) and ‘borrowing’ (OR = 1.68) to finance OPP were significantly higher among angina households.

Conclusions

The cost of chronic care in Ukraine places a burden on individual patient households. Households of angina patients are more likely to engage in distress financing to cover the cost of treatment, and a high proportion of patients do not acquire prescribed medicines because they cannot afford them. This warrants further research on the burden of NCD care in other LMIC, especially where OPP for health care is common. Health policies aimed at reducing OPP for health care, and especially medicines, would lessen the high health and financial burden of chronic care. Further research is also needed on the long-term impact of borrowing or sale of assets to finance OPP on patient households.

Does enrollment status in community-based insurance lead to poorer quality of care? Evidence from Burkina Faso

INTRODUCTION

In 2004, a community-based health insurance (CBI) scheme was introduced in Nouna health district, Burkina Faso, with the objective of improving financial access to high quality health services. We investigate the role of CBI enrollment in the quality of care provided at primary-care facilities in Nouna district, and measure differences in objective and perceived quality of care and patient satisfaction between enrolled and non-enrolled populations who visit the facilities.

METHODS

We interviewed a systematic random sample of 398 patients after their visit to one of the thirteen primary-care facilities contracted with the scheme; 34% (n = 135) of the patients were currently enrolled in the CBI scheme. We assessed objective quality of care as consultation, diagnostic and counselling tasks performed by providers during outpatient visits, perceived quality of care as patient evaluations of the structures and processes of service delivery, and overall patient satisfaction. Two-sample t-tests were performed for group comparison and ordinal logistic regression (OLR) analysis was used to estimate the association between CBI enrollment and overall patient satisfaction.

RESULTS

Objective quality of care evaluations show that CBI enrollees received substantially less comprehensive care for outpatient services than non-enrollees. In contrast, CBI enrollment was positively associated with overall patient satisfaction (aOR = 1.51, p = 0.014), controlling for potential confounders such as patient socio-economic status, illness symptoms, history of illness and characteristics of care received.

CONCLUSIONS

CBI patients perceived better quality of care, while objectively receiving worse quality of care, compared to patients who were not enrolled in CBI. Systematic differences in quality of care expectations between CBI enrollees and non-enrollees may explain this finding. One factor influencing quality of care may be the type of provider payment used by the CBI scheme, which has been identified as a leading factor in reducing provider motivation to deliver high quality care to CBI enrollees in previous studies. Based on this study, it is unlikely that perceived quality of care and patient satisfaction explain the low CBI enrollment rates in this community.

CAUSAL EFFECTS OF HEALTH SHOCKS ON CONSUMPTION AND DEBT: QUASI-EXPERIMENTAL EVIDENCE FROM BUS ACCIDENT INJURIES

Endogeneity between health and wealth presents a challenge for estimating causal effects of health shocks. Using a quasi-experimental design, comprising exogenous shocks sustained as bus accident injuries in India, with controls drawn from travelers on the same bus routes one year later, I present new evidence of causal effects on consumption and debt. Using primary household survey data, I find that households faced with shock-related expenditures are able to smooth consumption on food, housing, and festivals, with small reductions in educational spending. Debt was the principal mitigating mechanism households used, leading to significantly larger levels of indebtedness.

Investigating the affordability of key health services in South Africa

This paper considers the affordability of using public sector health services for three tracer conditions (obstetric care, tuberculosis treatment and antiretroviral treatment for HIV-positive people), based on research undertaken in two urban and two rural sites in South Africa. We understand affordability as the 'degree of fit' between the costs of seeking health care and a household's ability-to-pay. Exit interviews were conducted with over 300 patients for each of the three tracer conditions in each of the four sites (i.e. a total sample of over 3600). Total direct costs for the service used at the time of the interview, as well as other health related costs incurred during the preceding month either for self-care or the use of plural providers were assessed, as were a range of indicators of ability-to-pay. The percentage of households incurring direct costs exceeding 10% of household consumption expenditure and those borrowing money or selling assets as a mechanism for coping with the burden of direct costs were calculated. Logistic regressions were also conducted to identify factors that were significantly associated with these indicators of affordability. There were significant differences in affordability between rural and urban sites; costs were higher, ability-to-pay was lower and there was a greater proportion of households selling assets or borrowing money in rural areas. There were also significant differences across tracers, with a higher percentage of households receiving tuberculosis and antiretroviral treatment borrowing money or selling assets than those using obstetric services. As these conditions require expenses to be incurred on an ongoing basis, the sustainability of such coping strategies is questionable. Policy makers need to explore how to reduce direct costs for users of these key health services in the context of the particular characteristics of different treatment types. Affordability needs to be considered in relation to the dynamic aspects of the costs of treating different conditions and the timing of treatment in relation to diagnosis. The frequently high transport costs associated with treatments involving multiple consultations can be addressed by initiatives that provide close-to-client services and subsidised patient transport for referrals.

People, plants and health: a conceptual framework for assessing changes in medicinal plant consumption

BACKGROUND

A large number of people in both developing and developed countries rely on medicinal plant products to maintain their health or treat illnesses. Available evidence suggests that medicinal plant consumption will remain stable or increase in the short to medium term. Knowledge on what factors determine medicinal plant consumption is, however, scattered across many disciplines, impeding, for example, systematic consideration of plant-based traditional medicine in national health care systems. The aim of the paper is to develop a conceptual framework for understanding medicinal plant consumption dynamics. Consumption is employed in the economic sense: use of medicinal plants by consumers or in the production of other goods.

METHODS

PubMed and Web of Knowledge (formerly Web of Science) were searched using a set of medicinal plant key terms (folk/peasant/rural/traditional/ethno/indigenous/CAM/herbal/botanical/phytotherapy); each search terms was combined with terms related to medicinal plant consumption dynamics (medicinal plants/health care/preference/trade/treatment seeking behavior/domestication/sustainability/conservation/urban/migration/climate change/policy/production systems). To eliminate studies not directly focused on medicinal plant consumption, searches were limited by a number of terms (chemistry/clinical/in vitro/antibacterial/dose/molecular/trial/efficacy/antimicrobial/alkaloid/bioactive/inhibit/antibody/purification/antioxidant/DNA/rat/aqueous). A total of 1940 references were identified; manual screening for relevance reduced this to 645 relevant documents. As the conceptual framework emerged inductively, additional targeted literature searches were undertaken on specific factors and link, bringing the final number of references to 737.

RESULTS

The paper first defines the four main groups of medicinal plant users (1. Hunter-gatherers, 2. Farmers and pastoralists, 3. Urban and peri-urban people, 4. Entrepreneurs) and the three main types of benefits (consumer, producer, society-wide) derived from medicinal plants usage. Then a single unified conceptual framework for understanding the factors influencing medicinal plant consumption in the economic sense is proposed; the framework distinguishes four spatial levels of analysis (international, national, local, household) and identifies and describes 15 factors and their relationships.

CONCLUSIONS

The framework provides a basis for increasing our conceptual understanding of medicinal plant consumption dynamics, allows a positioning of existing studies, and can serve to guide future research in the area. This would inform the formation of future health and natural resource management policies.

Treatment actions and treatment failure: case studies in the response to severe childhood febrile illness in Mali

Background

Appropriate home management of illness is vital to efforts to control malaria. The strategy of home management relies on caregivers to recognize malaria symptoms, assess severity and promptly seek appropriate care at a health facility if necessary. This paper examines the management of severe febrile illness (presumed malaria) among children under the age of five in rural Koulikoro Region, Mali.

Methods

This research examines in-depth case studies of twenty-five households in which a child recently experienced a severe febrile illness, as well as key informant interviews and focus group discussions with community members. These techniques were used to explore the sequence of treatment steps taken during a severe illness episode and the context in which decisions were made pertaining to pursing treatments and sources of care, while incorporating the perspective and input of the mother as well as the larger household.

Results

Eighty-one participants were recruited in 25 households meeting inclusion criteria. Children's illness episodes involved multiple treatment steps, with an average of 4.4 treatment steps per episode (range: 2–10). For 76% of children, treatment began in the home, but 80% were treated outside the home as a second recourse. Most families used both traditional and modern treatments, administered either inside the home by family members, or by traditional or modern healers. Participants’ stated preference was for modern care, despite high rates of reported treatment failure (52%, n=12), however, traditional treatments were also often deemed appropriate and effective. The most commonly cited barrier to seeking care at health facilities was cost, especially during the rainy season. Financial constraints often led families to use traditional treatments.

Conclusions

Households have few options available to them in moments of overlapping health and economic crises. Public health research and policy should focus on the reducing barriers that inhibit poor households from promptly seeking appropriate health care. Enhancing the quality of care provided at community health facilities and supporting mechanisms by which treatment failures are quickly identified and addressed can contribute to reducing subsequent treatment delays and avoid inappropriate recourse to traditional treatments.

Capitals diminished, denied, mustered and deployed. A qualitative longitudinal study of women's four year trajectories after acute health crisis, Burkina Faso

Accumulating evidence indicates that health crises can play a key role in precipitating or exacerbating poverty. For women of reproductive age in low-income countries, the complications of pregnancy are a common cause of acute health crisis, yet investigation of longer-term dynamics set in motion by such events, and their interactions with other aspects of social life, is rare. This article presents findings from longitudinal qualitative research conducted in Burkina Faso over 2004–2010. Guided by an analytic focus on patterns of continuity and change, and drawing on recent discussions on the notion of ‘resilience’, and the concepts of ‘social capital’ and ‘bodily capital’, we explore the trajectories of 16 women in the aftermath of costly acute healthcare episodes. The synthesis of case studies shows that, in conditions of structural inequity and great insecurity, an individual's social capital ebbs and flow over time, resulting in a trajectory of multiple adaptations. Women's capacity to harness or exploit bodily capital in its various forms (beauty, youthfulness, physical strength, fertility) to some extent determines their ability to confront and overcome adversities. With this, they are able to further mobilise social capital without incurring excessive debt, or to access and accumulate significant new social capital. Temporary self-displacement, often to the parental home, is also used as a weapon of negotiation in intra-household conflict and to remind others of the value of one's productive and domestic labour. Conversely, diminished bodily capital due to the physiological impact of an obstetric event or its complications can lead to reduced opportunities, and to further disadvantage.

Measuring women's perceived ability to overcome barriers to healthcare seeking in Burkina Faso

Background

In sub-Saharan Africa, women must overcome numerous barriers when they need modern healthcare. Respect of gender norms within the household and the community may still influence women's ability to obtain care. A lack of gender-sensitive instruments for measuring women's ability to overcome barriers compromises attempts to adequately quantify the burden and risk of exclusion they face when seeking modern healthcare. The aim of this study was to create and validate a synthetic measure of women's access to healthcare from a publicly available and possibly internationally comparable population-based survey.

Method

Seven questionnaire items from the Burkina Faso 2003 DHS were combined to create the index. Cronbach's alpha coefficient was used to test the reliability of the index. Exploratory factor analyses (EFA) and confirmatory factor analyses (CFA) were applied to evaluate the factorial structure and construct validity of the index while taking into account the hierarchical structure of the data.

Results

The index has a Cronbach's alpha of 0.75, suggesting adequate reliability. In EFA, three correlated factors fitted the data best. In CFA, the construct of perceived ability to overcome barriers to healthcare seeking emerged as a second-order latent variable with three domains: socioeconomic barriers, geographical barriers and psychosocial barriers. Model fit indices support the index's global validity for women of reproductive age in Burkina Faso. Evidence for construct validity comes from the finding that women's index scores increase with household living standard.

Conclusion

The DHS items can be combined into a reliable and valid, gender-sensitive index quantifying reproductive-age women's perceived ability to overcome barriers to healthcare seeking in Burkina Faso. The index complies conceptually with the sector-cross-cutting capability approach and enables measuring directly the perceived access to healthcare. Therefore it can help to improve the design and evaluation of interventions that aim to facilitate healthcare seeking in this country. Further analyses may examine how far the index applies to similar contexts.

Hardship financing of healthcare among rural poor in Orissa, India

BACKGROUND

This study examines health-related "hardship financing" in order to get better insights on how poor households finance their out-of-pocket healthcare costs. We define hardship financing as having to borrow money with interest or to sell assets to pay out-of-pocket healthcare costs.

METHODS

Using survey data of 5,383 low-income households in Orissa, one of the poorest states of India, we investigate factors influencing the risk of hardship financing with the use of a logistic regression.

RESULTS

Overall, about 25% of the households (that had any healthcare cost) reported hardship financing during the year preceding the survey. Among households that experienced a hospitalization, this percentage was nearly 40%, but even among households with outpatient or maternity-related care around 25% experienced hardship financing.Hardship financing is explained not merely by the wealth of the household (measured by assets) or how much is spent out-of-pocket on healthcare costs, but also by when the payment occurs, its frequency and its duration (e.g. more severe in cases of chronic illnesses). The location where a household resides remains a major predictor of the likelihood to have hardship financing despite all other household features included in the model.

CONCLUSIONS

Rural poor households are subjected to considerable and protracted financial hardship due to the indirect and longer-term deleterious effects of how they cope with out-of-pocket healthcare costs. The social network that households can access influences exposure to hardship financing. Our findings point to the need to develop a policy solution that would limit that exposure both in quantum and in time. We therefore conclude that policy interventions aiming to ensure health-related financial protection would have to demonstrate that they have reduced the frequency and the volume of hardship financing.

Informal payments and intra-household allocation of resources for health care in Albania

BACKGROUND

Informal payments for health care services can impose financial hardship on households. Many studies have found that the position within the household can influence the decision on how much is spent on each household member. This study analyses the intra-household differences in spending on informal payments for health care services by comparing the resources allocated between household heads, spouses and children.

METHODS

Pooled data from two cross sectional surveys, the Albanian Living Standard Measurement Survey 2002 and 2005, are used to analyse both the probability and the amount paid in inpatient and outpatient health care services. A generalised Hausman specification test is used to compare the coefficients of probit and OLS models for nuclear and extended households.

RESULTS

We find that due to the widespread informal payments there are no significant differences between households in the incidence of informal payments for households' members, but there are more differences in the amount paid informally. Results suggest that households strategically allocate their resources on health care by favouring individuals with higher earning potential who have invested more in human capital. Extended households pay higher amounts for spouses with higher education compared to nuclear households. On the other hand, nuclear households choose to pay higher amounts for children with a higher level of education compared to extended households.

CONCLUSIONS

The differences between households should be taken into account by public policies which should compensate this by redistribution mechanisms targeting disadvantaged groups. Governments should implement effective measures to deal with informal patient payments. JEL Codes: I10, I19, D10.

Health insurance and health-seeking behavior: evidence from a randomized community-based insurance rollout in rural Burkina Faso

In 2004, a community-based health insurance (CBI) scheme was introduced in Nouna district, Burkina Faso, with the primary objective of improving access to facility-based health services. In order to overcome self-selection issues in the analysis of the behavioral effects of insurance, we combine four waves of the Nouna Health District Household Survey into a panel data set, and use the randomized timing of insurance rollout to estimate the causal effect of insurance coverage on health-seeking behavior. While we find a generally positive association between CBI affiliation and treatment seeking, we cannot reject the null that the introduction of health insurance does not have any effect on treatment seeking in general, and utilization of facility-based professional care, in particular. Low levels of health care provider satisfaction, poor perceived quality of care by enrollees, and ambiguity in the coverage level of the CBI benefit package appear to have contributed to these weak results. Our findings imply that the basic notion of insurance mechanically increasing facility-based professional care is not necessarily true empirically, and likely contingent on a large number of contextual factors affecting health-seeking behavior within households and communities.

Households' perception of climate change and human health risks: a community perspective

BACKGROUND

Bangladesh has been identified as one of the most vulnerable countries in the world concerning the adverse effects of climate change (CC). However, little is known about the perception of CC from the community, which is important for developing adaptation strategies.

METHODS

The study was a cross-sectional survey of respondents from two villages--one from the northern part and the other from the southern part of Bangladesh. A total of 450 households were selected randomly through multistage sampling completed a semi-structure questionnaire. This was supplemented with 12 focus group discussions (FGDs) and 15 key informant interviews (KIIs).

RESULTS

Over 95 percent of the respondents reported that the heat during the summers had increased and 80.2 percent reported that rainfall had decreased, compared to their previous experiences. Approximately 65 percent reported that winters were warmer than in previous years but they still experienced very erratic and severe cold during the winter for about 5-7 days, which restricted their activities with very destructive effect on agricultural production, everyday life and the health of people. FGDs and KIIs also reported that overall winters were warmer. Eighty point two percent, 72.5 percent and 54.7 percent survey respondents perceived that the frequency of water, heat and cold related diseases/health problems, respectively, had increased compared to five to ten years ago. FGDs and KIIs respondents were also reported the same.

CONCLUSIONS

Respondents had clear perceptions about changes in heat, cold and rainfall that had occurred over the last five to ten years. Local perceptions of climate variability (CV) included increased heat, overall warmer winters, reduced rainfall and fewer floods. The effects of CV were mostly negative in terms of means of living, human health, agriculture and overall livelihoods. Most local perceptions on CV are consistent with the evidence regarding the vulnerability of Bangladesh to CC. Such findings can be used to formulate appropriate sector programs and interventions. The systematic collection of such information will allow scientists, researchers and policy makers to design and implement appropriate adaptation strategies for CC in countries that are especially vulnerable.

Does the distribution of health care benefits in Kenya meet the principles of universal coverage?

BACKGROUND

The 58th World Health Assembly called for all health systems to move towards universal coverage where everyone has access to key promotive, preventive, curative and rehabilitative health interventions at an affordable cost. Universal coverage involves ensuring that health care benefits are distributed on the basis of need for care and not on ability to pay. The distribution of health care benefits is therefore an important policy question, which health systems should address. The aim of this study is to assess the distribution of health care benefits in the Kenyan health system, compare changes over two time periods and demonstrate the extent to which the distribution meets the principles of universal coverage.

METHODS

Two nationally representative cross-sectional households surveys conducted in 2003 and 2007 were the main sources of data. A comprehensive analysis of the entire health system is conducted including the public sector, private-not-for-profit and private-for-profit sectors. Standard benefit incidence analysis techniques were applied and adopted to allow application to private sector services.

RESULTS

The three sectors recorded similar levels of pro-rich distribution in 2003, but in 2007, the private-not-for-profit sector was pro-poor, public sector benefits showed an equal distribution, while the private-for-profit sector remained pro-rich. Larger pro-rich disparities were recorded for inpatient compared to outpatient benefits at the hospital level, but primary health care services were pro-poor. Benefits were distributed on the basis of ability to pay and not on need for care.

CONCLUSIONS

The principles of universal coverage require that all should benefit from health care according to need. The Kenyan health sector is clearly inequitable and benefits are not distributed on the basis of need. Deliberate efforts should be directed to restructuring the Kenyan health system to address access barriers and ensure that all Kenyans benefit from health care when they need it.

Socioeconomic-related health inequality in South Africa: evidence from General Household Surveys

BACKGROUND

Inequalities in health have received considerable attention from health scientists and economists. In South Africa, inequalities exist in socio-economic status (SES) and in access to basic social services and are exacerbated by inequalities in health. While health systems, together with the wider social determinants of health, are relevant in seeking to improve health status and health inequalities, those that need good quality health care too seldom get it. Studies on the burden of ill-health in South Africa have shown consistently that, relative to the wealthy, the poor suffer more from more disease and violence. However, these studies are based on selected disease conditions and only consider a single point in time. Trend analyses have yet to be produced. This paper specifically investigates socio-economic related health inequality in South Africa and seeks to understand how the burden of self-reported illness and disability is distributed and whether this has changed since the early 2000s.

METHODS

Several rounds (2002, 2004, 2006, and 2008) of the South African General Household Surveys (GHS) data were used, with standardized and normalized self-reported illness and disability concentration indices to assess the distribution of illness and disability across socio-economic groups. Composite indices of socio-economic status were created using a set of common assets and household characteristics.

RESULTS

This study demonstrates the existence of socio-economic gradients in self-reported ill-health in South Africa. The burden of the major categories of ill-health and disability is greater among lower than higher socio-economic groups. Even non-communicable diseases, which are frequently seen as diseases of affluence, are increasingly being reported by lower socio-economic groups. For instance, the concentration index of flu (and diabetes) declined from about 0.17 (0.10) in 2002 to 0.05 (0.01) in 2008. These results have also been confirmed internationally.

CONCLUSION

The current burden and distribution of ill-health indicates how critical it is for the South African health system to strive for access to and use of health services that is in line with need for such care. Concerted government efforts, within both the health sector and other social and economic sectors are therefore needed to address the significant health inequalities in South Africa.

Inequities in access to health care in South Africa

Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n = 4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.

Managing in the contemporary world: rape victims' and supporters' experiences of barriers within the police and the health care system in Tanzania

Grounded theory guided the analysis of 30 in-depth interviews with raped women and community members who had supported raped women in their contact with the police and health care services in Tanzania. The aim of this study was to understand and conceptualize the experiences of the informants by creating a theoretical model focusing on barriers, strategies, and responses during the help seeking process. The results illustrate a process of managing in the contemporary world characterized as walking a path of anger and humiliation. The barriers are illustrated by painful experiences of realizing it's all about money, meeting unprofessionalism and irresponsibility, subjected to unreliable services, and by being caught in a messed-up system. Negotiating truths and knowing what to do capture the informants' coping strategies. The study indicates an urgent need for improvement in the formal procedures of handling rape cases, improved collaboration between the police and the health care system, as well as specific training for professionals to improve their communication and caring skills.

We can't afford my chronic illness! The out-of-pocket burden associated with managing chronic obstructive pulmonary disease in western Sydney, Australia

OBJECTIVES

To examine the household economic consequences that are associated with out-of-pocket spending for the care and management of chronic obstructive pulmonary disease (COPD).

METHODS

A cross-sectional study. A self-administered questionnaire was posted to all patients enrolled (n = 656) in the Respiratory Ambulatory Care Service in western Sydney, Australia, between 1 January 2001 and 31 August 2008. Two hundred and eighteen completed questionnaires were received.

RESULTS

One hundred and sixty-nine (78%) respondents experienced economic hardship while managing their illness. Fifty-nine (27%) reported being unable to pay for medical or dental expenses, 38 (18%) were unable to pay for medication, 59 (27%) were unable to pay rent or mortgage and 40 (19%) were unable to pay utility bills. Respondents experiencing economic hardship paid more out-of-pocket overall (=AUD$544 versus =AUD$280; t(148) = -2.03, P = 0.04) and for medications and oxygen specifically (=AUD$247 versus =AUD$125; t(83) = -3.98, P < 0.0001). Fifty-six (46%) respondents had catastrophic levels of out-of-pocket spending which made them 7.5 times more likely to experience economic hardship (95% confidence interval [CI]: 1.2-46.3).

CONCLUSIONS

The costs associated with living with COPD make it difficult for patients and their families to afford necessary living expenses while also paying health care expenses. This is alarming within Australia where a well-funded universal health insurance system is in place. Rising co-payments for medications and private medical consultations, poorly subsidised health support (e.g. home oxygen), non-health logistics (e.g. transport) and eligibility barriers for existing social support are making chronic illness management seriously economically stressful, especially for those with low incomes, including the retired.

Does community-based health insurance protect household assets? Evidence from rural Africa

OBJECTIVE

To evaluate whether community-based health insurance (CBHI) protects household assets in rural Burkina Faso, Africa.

DATA SOURCES

Data were used from a household panel survey that collected primary data from randomly selected households, covering 41 villages and one town, during 2004-2007(n = 890).

STUDY DESIGN

The study area was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004-2006. We applied different strategies to control for selection bias-ordinary least squares with covariates, two-stage least squares with instrumental variable, and fixed-effects models.

DATA COLLECTION

Household members were interviewed in their local language every year, and information was collected on demographic and socio-economic indicators including ownership of assets, and on self-reported morbidity.

PRINCIPAL FINDINGS

Fixed-effects and ordinary least squares models showed that CBHI protected household assets during 2004-2007. The two-stage least squares with instrumental variable model showed that CBHI increased household assets during 2004-2005.

CONCLUSIONS

In this study, we found that CBHI has the potential to not only protect household assets but also increase household assets. However, similar studies from developing countries that evaluate the impact of health insurance on household economic indicators are needed to benchmark these results with other settings.