Out-of-pocket payments and utilization of health care services in Albania: evidence from three districts

Just informal patient payments are not enough, 'personal connections' and knowledge of the 'rules' are also required: a logistic regression analysis of informal practices in health care in Ukraine

In Ukraine, patients and their family members face numerous barriers to health care services. In response, they use coping strategies, that are manifold and complex activities aimed at overcoming these barriers, the financial burden of the treatment, and the poor quality of health care services. These activities include formal and informal practices. Based on representative survey data from 2015 (N = 2,022), we identify patterns in the use of coping strategies, specific coping strategies used to secure good quality consultation and treatment, and analyse opinions and actions towards coping practices. We further analyse the factors associated with the last experience of coping and look at patterns of connection building. We find that the chances of using both money and connection as a coping strategy are higher for people with incomplete higher and highest levels of education. The size of this effect increases with the level of education. Older people, people with better health, and people with a higher opinion of the state use informal practices less, while women are more active in developing connections. The closer the relationship is with a medical doctor, the higher is the chance that such connection will be used in case of health service consumption.

Out-of-pocket health expenditure and associated factors among patients with hypertension in Debre-Tabor Comphrensive Specialized Hospital, South Gondar zone, Northwest Ethiopia, 2020

Introduction

Hypertension is a non-communicable chronic disease that has a wide financial effect at the individual and household levels especially in developing countries due to its complexity and chronicity. Nevertheless, there are limited studies in Ethiopia. Therefore the aim of this study was to assess out-of pocket health expenditure and associated factors among adult patients with hypertension in Debre-Tabor Comphrensive Specialized Hospital.

Methods

A facility-based cross-sectional study was conducted in total of 357 adult hypertensive patients from March to April 2020 using a systematic random sampling technique. Descriptive stastics were used to estimate the magnitude of out-of-pocket health expenditure, while after checking the assumptions linear regression model was fitted for identifying the factors associated with the outcome variable at a significance level of value of p < 0.05 and 95% confidence interval.

Result

A total of 346 study participants interviewed with a response rate of 96.92%. Annual mean out of pocket health expenditure of the participant was $113.40 ± $10.18 with 95% CI = (102.63, 124.16) per patient. The direct medical mean out of pocket health expenditure of the participant was $68.86 per patient per year and the median of non-medical components of the out of pocket health expenditure of the participant was $3.53. Sex, wealth status, distance from hospital, comorbidity, health insurance and number of visit are factors significantly associated to out-of-pocket expenditure.

Conclusion

This study revealed that out of pocket health expenditure among adult patients with hypertension was found high compared to the national per capita health expenditure. Sex, wealth index, distance away from hospital, frequency of visit, comorbidities, and health insurance coverage were factors significantly associated with high out-of-pocket health expenditure. Ministry of health together with regional health bureaus and other concerned stakeholders work on strengthening early detection and prevention strategies of chronic comorbidities of hypertensive patients,promote health insurance coverage and better to subsidize medication costs for the poors.

Determinants of Turkish households' out-of-pocket expenditures on three categories of health care services: A multivariate probit approach

This study identifies the driving forces that contribute to the probabilities of incidence of out-of-pocket (OOP) expenditures by households in Turkey. Factors affecting the probability of OOP expenditures on medical products/devices/supplies (MP), outpatient services (OTS), and inpatient services (ITS) are examined using the Household Budget Survey data gathered by the Turkish Statistical Institute in 2018. The study applies the multivariate probit model. The incidence of OOP spending varied with 48.9% of the households reporting OOP expenditure on MP, 22.4% on OTS, and 25.4% on ITS. The largest probability changes were associated with household disposable annual income, household type and size, age category, and having private health insurance. Gender and marital status also influenced expenditures in some categories. Lifestyle choices had small and mixed effects, with smoking and alcohol consumption lowering the probability of OOP spending. From a policy standpoint, households with the lowest incomes, large households, and those where the household head was 'others' (retiree, student, housewife, not actively working, etc.) or had a condition preventing employment seemed to report OOP expenditures less frequently and may have chosen not to receive healthcare services, leading to the need for more healthcare services later.

Out-of-pocket payments for treatment of COVID-19 in Iran

INTRODUCTION

Out-of-pocket (OOP) is among the payment methods in Iran's health system. The present study aimed to examine the OOP treatment costs for patients with COVID-19 in Iran.

METHODS

A descriptive-analytical, cross-sectional study was conducted in 2021. In this study, the cost records of 550 patients with COVID-19 hospitalized in a referral center of COVID-19 were selected using the stratified random sampling method. The required data were collected using a researcher-made questionnaire. Data were analyzed by t-test, ANOVA, and Pearson's correlation coefficient in SPSS software version 23 at p = 0.05.

RESULTS

The total direct costs were 1,037,992.15 US $. Moreover, the shares of patients (OOP), basic insurance, government subsidy, supplementary insurance, discounts, and out-of-government subsidy in the total direct costs were US $ 92,231.21, 746,932.99 US $, 155,127.08 US $, 39,690.25 US $ and 4010.61 US $, respectively. In addition, the results confirmed that there was a positive and significant relationship between the patients' OOP payments and the length of stay. It also found that the patients' OOP payments are subject to the type of insurance program and discharge method.

CONCLUSION

According to the results, 8.89% of the total direct costs were directly paid out of the patients' pockets. The research findings confirm the urgent need to make decisions and implement effective interventions for COVID-19 disease by controlling risk factors and exploiting other countries' successful experiences and international organizations' recommendations to decrease the prevalence of the infected and consequently reduce the financial pressure of the disease on patients by approving the expansion of the insurance organizations' role.

A STUDY OF CATASTROPHIC HEALTH EXPENDITURES IN INDIA - EVIDENCE FROM NATIONALLY REPRESENTATIVE SURVEY DATA: 2014-2018

Abstract

Background: India is taking steps to provide Universal Health Coverage (UHC). Out-of-pocket (OOP) health care payment is the most important mechanism for health care payment in India. This study aims to investigate the effect of OOP health care payments on catastrophic health expenditures (CHE).

Methods: Data from the National Sample Survey Organization, Social Consumption in Health 2014 and 2018 are used to investigate the effect of OOP health expenditure on household welfare in India. Three aspects of catastrophic expenditure were analyzed in this paper: (i) incidence and intensity of ‘catastrophic’ health expenditure, (ii) socioeconomic inequality in catastrophic health expenditures, and (iii) factors affecting catastrophic health expenditures.

Results: The odds of incidence and intensity of CHE were higher for the poorer households. Using the logistic regression model, it was observed that the odds of incidence of CHE was higher among the households with at least one child aged less than 5 years, one elderly person, one secondary educated female member, and if at least one member in the household used a private healthcare facility for treatment. The multiple regression model showed that the intensity of CHE was higher among households with members having chronic illness, and if members had higher duration of stay in the hospital. Subsidizing healthcare to the households having elderly members and children is necessary to reduce CHE.

Conclusion: Expanding health insurance coverage, increasing coverage limits, and inclusion of coverage for outpatient and preventive services are vital to protect households. Strengthening public primary health infrastructure and setting up a regulatory organization to establish policies and conduct regular audits to ensure that private hospitals do not increase hospitalizations and the duration of stay is necessary.

Civil Servants and Non-Western Migrants' Perceptions on Pathways to Health Care in Serbia-A Grounded Theory, Multi-Perspective Study

(1) Background: Informal patient payments continue to persist in the Serbian health care system, exposing vulnerable groups to private spending on health care. Migrants may in particular be subject to such payments, as they often experience barriers in access to health care. Little is known about migrants paying informally to access health care in Serbia. The study aims to explore pathways of accessing health care, including the role of informal patient payments, from the perspectives of civil servants and non-western migrants in Serbia. (2) Methods: Respondents (n = 8 civil servants and n = 6 migrants) were recruited in Belgrade in 2018, where semi-structured interviews were conducted. The interviews were analysed applying the grounded theory methodological steps. (3) Results: Data reveal different pathways to navigate the Serbian health care system, and ultimately whether paying informally occurs. Migrants appear less prone to paying informally and receive the same or better-quality health care. Locals experience the need to pay informal patient payments, quasi-formal payments and to bring medicine, materials or equipment when in health facilities. (4) Conclusions: Paying informally or using private care in Serbia appear to have become common. Despite a comprehensive health insurance coverage, high levels of out-of-pocket payments show barriers in accessing health care. It is highly important to not confuse the cultural beliefs with forced spending on health care and such private spending should be reduced to not push people into poverty.

An empirical study on the determinants of health care expenses in emerging economies

BACKGROUND

Emerging countries continue to suffer gravely from insufficient healthcare funding, which adversely affects access to quality healthcare and ultimately the health status of citizens. By using panel data from the World Development Indicators, the study examined the determinants of health care expenditure among twenty-two (22) emerging countries from the year 2000 to 2018.

METHODS

The study employed cross-section dependence and homogeneity tests to confirm cross-sectional dependence and to deal with homogeneity issues. The Quantile regression technique is employed to test for the relationship between private and public health care expenses and its determinants. The Pooled mean group causality test is used to examine the causal connections among the variables.

RESULTS

The outcome of the quantile regression test revealed that economic growth and aging population could induce healthcare costs in emerging countries. However, the impact of industrialization, agricultural activities, and technological advancement on health expenses are found to be noticeably heterogeneous at the various quantile levels. Unidirectional causality was found between industrialization and public health expenses; whereas two-way causal influence was reveled amongst public health expenditure and GDP per capita; public health expenditure and agricultural activities.

CONCLUSION

It is therefore suggested that effective and integrated strategies should be considered by industries and agricultural sectors to help reduce preventable diseases that will ultimately reduce healthcare costs among the emerging countries.

Costs incurred by outpatients at a university hospital in northwestern Ethiopia: a cross-sectional study

Background

Out-of-pocket expenditure constitutes high proportion of healthcare spending in low-income countries. It can affect patients’ adherence to treatments leading to serious health consequences. The objective of this study was to document costs incurred by patients visiting Gondar University Referral Hospital, in Gondar, northwestern Ethiopia.

Methods

An institution-based cross-sectional study was conducted among 346 outpatients at the hospital from 2nd to 20th of May 2016. Data collection took place through interviews with patients coming to the outpatient pharmacy after finishing their visits at the different departments in the hospital. Data were collected on socio-demographic information, cost incurred before and during hospital visit as well as ownership of household items.

Results

Among the 342 interviews included in the final analysis, a median total cost of 22.25 USD was incurred by patients. This constituted spending on solutions tried before hospital visit, direct medical, nonmedical and indirect costs. Among these, direct nonmedical and indirect costs constituted a large share. Medicine, transportation and waiting time during visit were major components of direct medical, nonmedical and indirect costs respectively. Total median cost was found to be predicted by residence, marital status and payment scheme used to pay for hospital services.

Conclusions

Outpatients visiting the hospital incurred significant costs for illnesses/conditions associated with their visit to the hospital, the main components being nonmedical and indirect costs. Residence, marital status and payment scheme, predicted median total cost. Direct nonmedical costs and indirect costs were found to be significant components associated to the spending and loss of earning by patients and their families in their trip to and from the hospital.

Gasto de bolsillo y gasto catastrófico en salud en los hogares de Cartagena, Colombia

Objetivo Estimar el gasto de bolsillo y la probabilidad de gasto catastrófico de los hogares y sus determinantes socioeconómicos en Cartagena, Colombia.Materiales y Métodos Estudio transversal en una muestra poblacional estratificada aleatoria de hogares de Cartagena. Se estimaron dos modelos de regresión cuyas variables dependientes fueron gasto de bolsillo y probabilidad de gasto catastrófico en salud de los hogares.Resultados El gasto de bolsillo promedio anual en hogares pobres fue 1 566 036 COP (US$783) (IC95% 1 117 597–2 014 475); en hogares de estrato medio 2 492 928 COP (US$1246) (IC95% 1 695 845-3 290 011) y en hogares ricos 4 577 172 COP (US$2 288) (IC95% 1 838 222-7 316 122). Como proporción del ingreso, el gasto de bolsillo en salud fue de 14,6% en los hogares pobres, de 8,2% en los hogares de estrato medio y de 7,0% en los hogares ricos. La probabilidad de gasto catastrófico en salud de los hogares pobres fue 30,6% (IC95% 25,6-35,5%), de los de estrato medio del 10,2% (IC95% 4,5-15,9%) y de los hogares de estrato alto del 8,6% (IC95% 1,8-23,0%). El estrato socioeconómico, la educación y la ocupación fueron los principales determinantes del gasto de bolsillo en salud y de la probabilidad de incurrir en gasto catastrófico en salud.Conclusiones En el sistema de salud persisten desigualdades en la protección financiera de los hogares contra el gasto de bolsillo y la probabilidad de gasto catastrófico. El presente estudio genera evidencia para revisar la política de protección social de los hogares socioeconómicamente más vulnerables.

Reduction and elimination solutions of informal payment in Iran's health system

Background: Informal payments can cause delayed access to health care services, forcing people to sell their properties for cost of treatment; and as a result, they lose trust in the health system. Considering the importance of this issue, this study was conducted in 2016 to identify solutions to reduce and eliminate informal payments in Iran's health system. Methods: Initially, solutions to reduce informal payments were extracted by reviewing resources and searching Persian and Englishlanguage databases including Science direct, PubMed, Scopus, Medline, ISC, Magiran, SID using the following keywords: informal payments, under the table payment, bribes, gratitude payment, and informal payments/fees. Then, Iranian context specific solutions were obtained by performing semi-structured interviews with 19 individuals, who were aware of the problem. Next, the identified strategies were confirmed using Delphi technique and with the participation of 50 experts. Results: Various solutions were identified and confirmed to reduce or eliminate informal payments in Iran's health system, which are divisible in different economical fields, such as payments to providers based on performance, religious leaders' fatwa (sociocultural), disclosing the offenders' names (legal-political), and using family doctor system (structural). Conclusion: The proposed solutions can be used by policymakers and managers in the health sector to manage informal payments. Careful identification of health care providers and recipients' motivations and needs can be effective in recognizing and eliminating this phenomenon.

Within the triangle of healthcare legacies: comparing the performance of South-Eastern European health systems

OBJECTIVE

Inter-regional comparison of health-reform outcomes in south-eastern Europe (SEE).

METHODS

Macro-indicators were obtained from the WHO Health for All Database. Inter-regional comparison among post-Semashko, former Yugoslavia, and prior-1989-free-market SEE economies was conducted.

RESULTS

United Nations Development Program Human Development Index growth was strongest among prior-free-market SEE, followed by former Yugoslavia and post-Semashko. Policy cuts to hospital beds and nursing-staff capacities were highest in post-Semashko. Physician density increased the most in prior-free-market SEE. Length of hospital stay was reduced in most countries; frequency of outpatient visits and inpatient discharges doubled in prior-free-market SEE. Fertility rates fell for one third in Post-Semashko and prior-free-market SEE. Crude death rates slightly decreased in prior-free-market-SEE and post-Semashko, while growing in the former Yugoslavia region. Life expectancy increased by 4 years on average in all regions; prior-free-market SEE achieving the highest longevity. Childhood and maternal mortality rates decreased throughout SEE, while post-Semashko countries recorded the most progress.

CONCLUSIONS

Significant differences in healthcare resources and outcomes were observed among three historical health-policy legacies in south-eastern Europe. These different routes towards common goals created a golden opportunity for these economies to learn from each other.

Defining informal payments in healthcare: a systematic review

OBJECTIVES

To explore the literature for the definitions of informal payments in healthcare and critically analyze the proposed definitions. This will serve in the process of getting to a coherent definition of informal payments, which will further support acknowledging and addressing them globally.

METHODS

A search strategy was developed to identify papers addressing informal payments on PubMed, ScienceDirect, Econlit, EconPapers and Google Scholar.

RESULTS

2225 papers were identified after a first search. 61 papers were included in the systematic review. Out of all definitions provided, we selected three definitions as being original. All other definitions either cite these definitions or do not provide new insight into the topic of informal payments. Although informal payments have been nominated by various terms over the years, there is a tendency in recent years towards an agreement to use this singular term. Definitions differ in terms of the relation of informal payments with other informal activities, their legality and the motivation behind them.

CONCLUSIONS

The variety of forms which informal payments may take makes it difficult to define them in a comprehensive manner. However, we identified a definition that could serve as a beginning in this process. More effort is needed to build on it and get to a commonly accepted and shared definition of informal payments.

Paying informally in the Albanian health care sector: a two-tiered stochastic frontier model

Informal payments are deeply ingrained in the health care sector of most Central, Eastern and Southern European countries. Evidence suggests that the price paid informally to medical staff is negotiated either directly or indirectly between patients and medical staff. The aim of this paper is to measure the imperfect information that exists on the amount that has to be paid informally to medical staff. We measure the extent to which patients pay more than the amount medical staff expect informally and the extent to which medical staff request less than patients are willing to pay informally. A two-tiered stochastic frontier model is developed to estimate indicators of patients' and medical staff's imperfect information on informal payments and the effects on the amount the other party is minimally expecting or maximally willing to pay informally. The estimates are based on informal payments to medical staff in the inpatient health care sector in Albania. We use data from the Albania Living Standards Measurement Survey 2002 and 2005. The pooled samples include 707 individuals who have visited inpatient health care services in these 2 years. Our results show that medical staff has less information on the patients' maximum willingness to pay informally than patients have on medical staff's minimum expected amount. These estimates do not depend on categories of illnesses but on certain socio-demographic characteristics.

Medical education in Albania: Challenges and opportunities

Albania is a small south-eastern European country still recovering from almost half a century of a fierce communist regime. While major reform and support have focused on healthcare and higher education (HE) in the past decade, there have not been major attempts to improve medical education. The time is now ready for medical education improvements created by increasing internal and external pressures as Albania aims to align its HE with the European Union standards and adapts the Bologna system. This article presents a summary of the current status of undergraduate, postgraduate and continuous medical education in Albania and suggests opportunities for development and partnerships that would help the country's medical education reform.

Active pharmaceutical management strategies of health insurance systems to improve cost-effective use of medicines in low- and middle-income countries: a systematic review of current evidence

OBJECTIVES

Health insurance systems have great potential to improve the cost-effective use of medicines by leveraging better provider prescribing, more cost-effective use by consumers, and lower prices from industry. Despite ample evidence from high-income countries, little is known about insurance system strategies targeting medicines in low- and middle-income countries (LMIC). This paper provides a critical review of the literature on these strategies and their impacts in LMIC.

METHODS

We conducted a systematic review of published peer-reviewed and grey literature and organized the insurance system strategies into four categories: medicines selection, purchasing, contracting and utilization management.

RESULTS

In n=63 reviewed publications we found reasonable evidence supporting the use of insurance as an overall strategy to improve access to pharmaceuticals and outcomes in LMIC. Beyond this, most of the literature focused on provider contracting strategies to influence prescribing. There was very little evidence on medicines selection, purchasing, or utilization management strategies.

CONCLUSIONS

There is a paucity of published evidence on the impact of insurance system strategies on improving the use of medicines in LMIC. The existing evidence is questionable since the majority of the published studies utilize weak study designs. This review highlights the need for well-designed studies to build an evidence base on the impact of medicines management strategies deployed by LMIC insurance programs.

Addressing the phenomenon of bypassing in Albania: the impact of a primary health care strengthening intervention

The purpose of this study is to assess the impact of a primary health care strengthening intervention on bypassing behavior in Albania, a middle-income country that has experienced substantial structural changes that affect PHC and where bypassing among health care clients is common. The intervention aimed to improve the quality of health care in low-level facilities through improved availability and use of health information, the adoption of clinical practice guidelines, and provider training. The study employs a quasi-experimental research design to evaluate the impact of the intervention on health care utilization. The survey findings suggest that the pilot areas outperformed the control areas with respect to a number of key population-based indicators of health care utilization. For example, in the 2-year period between December 2002 and December 2004, bypassing for treatment of simple acute health problems during the month prior to the survey decreased by 47%, and the percentage of chronically ill health care clients who utilized PHC facilities for treatment in the month prior to the survey increased by 29%. These differences, which are statistically significant at the 10% level or better, suggest that the improved performance in the pilot areas is attributable to the intervention.

Informal payments and the financing of health care in developing and transition countries

Informal, under-the-table payments to public health care providers are increasingly viewed as a critically important source of health care financing in developing and transition countries. With minimal funding levels and limited accountability, publicly financed and delivered care falls prey to illegal payments, which require payments that can exceed 100 percent of a country's median income. Methods to address the abuse include establishing official fees, combined with improved oversight and accountability for public health care providers, and a role for communities in holding providers accountable.