Making choices between prepayment and user charges in Zambia. What are the results for equity?

Cumulative incidence, distribution, and determinants of catastrophic health expenditure in Nepal: results from the living standards survey

BACKGROUND

Nepal has committed to the global community to achieve universal health coverage by 2030. Nevertheless, Nepal still has a high proportion of out-of-pocket health payment and a limited risk-pooling mechanism. Out-of-pocket payment for the healthcare services could result in catastrophic health expenditure (CHE). Evidence is required to effectively channel the efforts to lower those expenses in order to achieve universal health coverage. However, little is known about CHE and its determinants in a broad national context in Nepal. Therefore, this study was conducted to explore the cumulative incidence, distribution, and determinants of CHE in Nepal.

METHODS

Data were obtained from the nationally representative survey, the Nepal Living Standards Survey-third undertaken in 2010/11. Information from 5988 households was used for the analyses. Households were classified as having CHE when their out-of-pocket health payment was greater than or equal to 40% of their capacity to pay. Remaining households were classified as not having CHE. Logistic regression analyses were used to identify determinants of CHE.

RESULTS

Based on household-weighted sample, the cumulative incidence of CHE was 10.3% per month in Nepal. This incidence was concentrated in the far-western region and households in the poorer expenditure quartiles. Multivariable logistic regression revealed that households were more likely to face CHE if they; consisted of chronically ill member(s), have a higher burden of acute illness and injuries, have elderly (≥60 years) member(s), belonged to the poor expenditure quartile, and were located in the far-western region. In contrast, households were less likely to incur CHE when their household head was educated. Having children (≤5 years) in households did not significantly affect catastrophic health expenditure.

CONCLUSIONS

This study identified a high cumulative incidence of CHE. CHE was disproportionately concentrated in the poor households and households located in the far-western region. Policy-makers should focus on prioritizing households vulnerable to CHE. Interventions to reduce economic burden of out-of-pocket healthcare payment are imperative to lower incidences of CHE among those households. Improving literacy rate might also be useful in order to lower CHE and facilitate universal health coverage.

Patient access to health care and medicines across low-income countries

This study explores the issue of demand for health care and medicines in low-income country settings. Using the World Health Survey, multivariate analysis of cross-sectional household data from 35 low-income countries found that when ill, patient demand for health care to visit a clinic or hospital is inelastic ranging from -0.19 to 0.11. The main determinants of health seeking behaviour include having insurance, having a chronic condition, high household expenditure, and marital status. Women, the educated and those living in urban settings are more likely to seek care in a clinic. These findings suggest low-income patients will experience access problems, raising important policy implications to improve access to health care and medicines in these settings.

The impact of vouchers on the use and quality of health care in developing countries: a systematic review

One approach to delivering healthcare in developing countries is through voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health care. Using inclusion/exclusion criteria, a search of databases, key journals and websites review was conducted in October 2010. A narrative synthesis approach was taken to summarise and analyse five outcome categories: targeting, utilisation, cost efficiency, quality and health outcomes. Sub-group and sensitivity analyses were also performed. A total of 24 studies evaluating 16 health voucher programmes were identified. The findings from 64 outcome variables indicates: modest evidence that vouchers effectively target specific populations; insufficient evidence to determine whether vouchers deliver healthcare efficiently; robust evidence that vouchers increase utilisation; modest evidence that vouchers improve quality; no evidence that vouchers have an impact on health outcomes; however, this last conclusion was found to be unstable in a sensitivity analysis. The results in the areas of targeting, utilisation and quality indicate that vouchers have a positive effect on health service delivery. The subsequent link that they improve health was found to be unstable from the data analysed; another finding of a positive effect would result in robust evidence. Vouchers are still new and the number of published studies is limiting.

Access to a health facility and care-seeking for danger signs in children: before and after a community-based intervention in Lusaka, Zambia

OBJECTIVE

To assess the association of accessibility to a health facility with caregivers' care-seeking practices for children with danger signs before and after community-based intervention in Lusaka, Zambia.

METHOD

Health education on childhood danger signs was started in September 2003 at the monthly Growth Monitoring Program Plus (GMP+) service through various channels of health talk and one-on-one communication in a peri-urban area of Lusaka. Two repeated surveys were conducted: in 2003 to collect baseline data before the intervention and in 2006 for 3-year follow-up data. Caregivers who had perceived one or more danger signs in their children within 2 months of the surveys were eligible for the analysis. The association between appropriate and timely care-seeking practices and socio-demographic and socio-economic factors, attendance at community-based intervention and the distance to a health facility was examined with logistic regression analysis.

RESULTS

The percentage of caregivers immediately seeking care from health professionals increased from 56.1% (106/189) at baseline to 65.8% (148/225) at follow-up 3 years later (OR = 1.51, P < 0.05). Long distance to the health facility and low-household income negatively influenced caregivers' appropriate and timely care-seeking practices at baseline, but 3 years later, after the implementation of a community-based intervention, distance and household income were not significantly related to caregivers' care-seeking practices.

CONCLUSION

Poor accessibility to health facilities was a significant barrier to care-seeking in a peri-urban area. However, when caregivers are properly educated about danger signs and appropriate responses through community-based intervention, this barrier can be overcome through behavioural change in caregivers.