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Demsash AW. Spatial distribution and geographical heterogeneity factors associated with households' enrollment level in community-based health insurance. Front Public Health 2024; 12:1305458. [PMID: 38827604 PMCID: PMC11140031 DOI: 10.3389/fpubh.2024.1305458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 04/25/2024] [Indexed: 06/04/2024] Open
Abstract
Background Healthcare service utilization is unequal among different subpopulations in low-income countries. For healthcare access and utilization of healthcare services with partial or full support, households are recommended to be enrolled in a community-based health insurance system (CBHIS). However, many households in low-income countries incur catastrophic health expenditure. This study aimed to assess the spatial distribution and factors associated with households' enrollment level in CBHIS in Ethiopia. Methods A cross-sectional study design with two-stage sampling techniques was used. The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) data were used. STATA 15 software and Microsoft Office Excel were used for data management. ArcMap 10.7 and SaTScan 9.5 software were used for geographically weighted regression analysis and mapping the results. A multilevel fixed-effect regression was used to assess the association of variables. A variable with a p < 0.05 was considered significant with a 95% confidence interval. Results Nearly three out of 10 (28.6%) households were enrolled in a CBHIS. The spatial distribution of households' enrollment in the health insurance system was not random, and households in the Amhara and Tigray regions had good enrollment in community-based health insurance. A total of 126 significant clusters were detected, and households in the primary clusters were more likely to be enrolled in CBHIS. Primary education (AOR: 1.21, 95% CI: 1.05, 1.31), age of the head of the household >35 years (AOR: 2.47, 95% CI: 2.04, 3.02), poor wealth status (AOR: 0.31, 95% CI: 0.21, 1.31), media exposure (AOR: 1.35, 95% CI: 1.02, 2.27), and residing in Afar (AOR: 0.01, 95% CI: 0.003, 0.03), Gambela (AOR: 0.03, 95% CI: 0.01, 0.08), Harari (AOR: 0.06, 95% CI: 0.02, 0.18), and Dire Dawa (AOR: 0.02, 95% CI: 0.01, 0.06) regions were significant factors for households' enrollment in CBHIS. The secondary education status of household heads, poor wealth status, and media exposure had stationary significant positive and negative effects on the enrollment of households in CBHIS across the geographical areas of the country. Conclusion The majority of households did not enroll in the CBHIS. Effective CBHIS frameworks and packages are required to improve the households' enrollment level. Financial support and subsidizing the premiums are also critical to enhancing households' enrollment in CBHIS.
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Affiliation(s)
- Addisalem Workie Demsash
- Department of Health Informatics, Debre Berhan University, Asrat Woldeyes Health Science Campus, Debre Birhan, Ethiopia
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Mori AT, Mudenda M, Robberstad B, Johansson KA, Kampata L, Musonda P, Sandoy I. Impact of cash transfer programs on healthcare utilization and catastrophic health expenditures in rural Zambia: a cluster randomized controlled trial. FRONTIERS IN HEALTH SERVICES 2024; 4:1254195. [PMID: 38741917 PMCID: PMC11089190 DOI: 10.3389/frhs.2024.1254195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 04/08/2024] [Indexed: 05/16/2024]
Abstract
Background Nearly 100 million people are pushed into poverty every year due to catastrophic health expenditures (CHE). We evaluated the impact of cash support programs on healthcare utilization and CHE among households participating in a cluster-randomized controlled trial focusing on adolescent childbearing in rural Zambia. Methods and findings The trial recruited adolescent girls from 157 rural schools in 12 districts enrolled in grade 7 in 2016 and consisted of control, economic support, and economic support plus community dialogue arms. Economic support included 3 USD/month for the girls, 35 USD/year for their guardians, and up to 150 USD/year for school fees. Interviews were conducted with 3,870 guardians representing 4,110 girls, 1.5-2 years after the intervention period started. Utilization was defined as visits to formal health facilities, and CHE was health payments exceeding 10% of total household expenditures. The degree of inequality was measured using the Concentration Index. In the control arm, 26.1% of the households utilized inpatient care in the previous year compared to 26.7% in the economic arm (RR = 1.0; 95% CI: 0.9-1.2, p = 0.815) and 27.7% in the combined arm (RR = 1.1; 95% CI: 0.9-1.3, p = 0.586). Utilization of outpatient care in the previous 4 weeks was 40.7% in the control arm, 41.3% in the economic support (RR = 1.0; 95% CI: 0.8-1.3, p = 0.805), and 42.9% in the combined arm (RR = 1.1; 95% CI: 0.8-1.3, p = 0.378). About 10.4% of the households in the control arm experienced CHE compared to 11.6% in the economic (RR = 1.1; 95% CI: 0.8-1.5, p = 0.468) and 12.1% in the combined arm (RR = 1.1; 95% CI: 0.8-1.5, p = 0.468). Utilization of outpatient care and the risk of CHE was relatively higher among the least poor than the poorest households, however, the degree of inequality was relatively smaller in the intervention arms than in the control arm. Conclusions Economic support alone and in combination with community dialogue aiming to reduce early childbearing did not appear to have a substantial impact on healthcare utilization and CHE in rural Zambia. However, although cash transfer did not significantly improve healthcare utilization, it reduced the degree of inequality in outpatient healthcare utilization and CHE across wealth groups. Trial Registration https://classic.clinicaltrials.gov/ct2/show/NCT02709967, ClinicalTrials.gov, identifier (NCT02709967).
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Affiliation(s)
- Amani Thomas Mori
- Chr. Michelsen Institute, Bergen, Norway
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
| | - Mweetwa Mudenda
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
| | - Bjarne Robberstad
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kjell Arne Johansson
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Linda Kampata
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Patrick Musonda
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ingvild Sandoy
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
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Li Z, Chen Y, Ding J. Health Poverty Alleviation Project in Rural China: Impact on Poverty Vulnerability, Health Status, Healthcare Utilization, Health Expenditures. Risk Manag Healthc Policy 2023; 16:2685-2702. [PMID: 38095012 PMCID: PMC10716013 DOI: 10.2147/rmhp.s438352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/02/2023] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND China has lead to the inception of the Health Poverty Alleviation Project (HPAP) in 2015. While the previous studies suggest that, despite its apparent reduction in patients' financial strain, the long-term poverty reduction effects are yet to be fully elucidated. This study explores HPAP's enduring impact on poverty reduction and the potential moral hazards. METHODS Data were obtained from four waves of the China Health and Retirement Longitudinal Study (CHARLS) spanning 2011-2018. We employed difference-in-differences (DID) models to gauge HPAP's influence on participants' poverty vulnerability, health outcomes, and healthcare utilization. The dynamic DID model is employed to test the robustness of HPAP policy effects. The mediation effect models were used to understand HPAP policy outcomes through physical examinations and inpatient care. RESULTS Our dataset encompassed 40,384 participants, of which 5946 (14.72%) had been exposed to HPAP and 34,438 (85.28%) had not access. Our findings reveal that HPAP decreases poverty vulnerability by 3.3% (p < 0.01) and attenuates health deterioration by 1.84% (p < 0.01). Furthermore, HPAP enhances inpatient care utilization by 9.34% (p < 0.01) and self-treatment behaviors by 4.1% (p < 0.01) while significantly slashing outpatient and inpatient expenses (p < 0.05). The implementation of HPAP has significantly reduced healthcare costs by 72.8% (p < 0.05) out-of-pocket (OOP) payments of outpatient care during the past month for the last time, and 89.39% (p < 0.05) out-of-pocket (OOP) payments of inpatient care during past the year for the last time. Mechanistic analyses have shown that the indirect effect of the HPAP policy decreases poverty vulnerability by -0.132% (p < 0.05) physical examinations and -0.309% (p < 0.05) inpatient care. CONCLUSION The HPAP initiative markedly attenuates poverty vulnerability and forestalls health decline among the rural populace. Moreover, HPAP bolsters healthcare service use, such as physical examinations and inpatient care, primarily attributed to the release of pent-up demand rather than moral hazards.
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Affiliation(s)
- Zhipeng Li
- Qu Qiubai School of Government, Changzhou University, Changzhou City, People’s Republic of China
| | - Yuqian Chen
- School of Economics and Management, Shanghai University of Political Science and Law, Shanghai, People’s Republic of China
| | - Jing Ding
- School of Public Economics and Administration, Shanghai University of Finance and Economics, Shanghai, People’s Republic of China
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Wang X, Guo Y, Qin Y, Nicholas S, Maitland E, Liu C. Regional catastrophic health expenditure and health inequality in China. Front Public Health 2023; 11:1193945. [PMID: 37927884 PMCID: PMC10624124 DOI: 10.3389/fpubh.2023.1193945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/15/2023] [Indexed: 11/07/2023] Open
Abstract
Background Catastrophic health expenditures (CHE) can trigger illness-caused poverty and compound poverty-caused illness. Our study is the first regional comparative study to analyze CHE trends and health inequality in eastern, central and western China, exploring the differences and disparities across regions to make targeted health policy recommendations. Methods Using data from China's Household Panel Study (CFPS), we selected Shanghai, Henan and Gansu as representative eastern-central-western regional provinces to construct a unique 5-year CHE unbalanced panel dataset. CHE incidence was measured by calculating headcount; CHE intensity was measured by overshoot and CHE inequality was estimated by concentration curves (CC) and the concentration index (CI). A random effect model was employed to analyze the impact of household head socio-economic characteristics, the household socio-economic characteristics and household health utilization on CHE incidence across the three regions. Results The study found that the incidence and intensity of CHE decreased, but the degree of CHE inequality increased, across all three regions. For all regions, the trend of inequality first decreased and then increased. We also revealed significant differences across the eastern, central and western regions of China in CHE incidence, intensity, inequality and regional differences in the CHE influencing factors. Affected by factors such as the gap between the rich and the poor and the uneven distribution of medical resources, families in the eastern region who were unmarried, use supplementary medical insurance, and had members receiving outpatient treatment were more likely to experience CHE. Families with chronic diseases in the central and western regions were more likely to suffer CHE, and rural families in the western region were more likely to experience CHE. Conclusions The trends and causes of CHE varied across the different regions, which requires a further tilt of medical resources to the central and western regions; improved prevention and financial support for chronic diseases households; and reform of the insurance reimbursement policy of outpatient medical insurance. On a regional basis, health policy should not only address CHE incidence and intensity, but also its inequality.
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Affiliation(s)
- Xinyue Wang
- School of Management, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yan Guo
- School of Management, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yang Qin
- Dispatching and Operation Department, Construction and Management Bureau of the North Hu Bei Water Transfer Project, Wuhan, China
| | - Stephen Nicholas
- Australian National Institute of Management and Commerce, Sydney, NSW, Australia
- School of Economics and School of Management, Tianjin Normal University, Tianjin, China
- Research Institute for International Strategies, Guangdong University of Foreign Studies, Guangzhou, China
- Newcastle Business School, University of Newcastle, University Drive, Newcastle, NSW, Australia
| | - Elizabeth Maitland
- School of Management, University of Liverpool, Liverpool, United Kingdom
| | - Cai Liu
- School of Management, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Bolongaita S, Lee Y, Johansson KA, Haaland ØA, Tolla MT, Lee J, Verguet S. Financial hardship associated with catastrophic out-of-pocket spending tied to primary care services in low- and lower-middle-income countries: findings from a modeling study. BMC Med 2023; 21:356. [PMID: 37710266 PMCID: PMC10503078 DOI: 10.1186/s12916-023-02957-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/21/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Financial risk protection (FRP) is a key component of universal health coverage (UHC): all individuals must be able to obtain the health services they need without experiencing financial hardship. In many low-income and lower-middle-income countries, however, the health system fails to provide sufficient protection against high out-of-pocket (OOP) spending on health services. In 2018, OOP health spending comprised approximately 40% of current health expenditures in low-income and lower-middle-income countries. METHODS We model the household risk of catastrophic health expenditures (CHE), conditional on having a given disease or condition-defined as OOP health spending that exceeds a threshold percentage (10, 25, or 40%) of annual income-for 29 health services across 13 disease categories (e.g., diarrheal diseases, cardiovascular diseases) in 34 low-income and lower-middle-income countries. Health services were included in the analysis if delivered at the primary care level and part of the Disease Control Priorities, 3rd edition "highest priority package." Data were compiled from several publicly available sources, including national health accounts, household surveys, and the published literature. A risk of CHE, conditional on having disease, was modeled as depending on usage, captured through utilization indicators; affordability, captured via the level of public financing and OOP health service unit costs; and income. RESULTS Across all countries, diseases, and health services, the risk of CHE (conditional on having a disease) would be concentrated among poorer quintiles (6.8% risk in quintile 1 vs. 1.3% in quintile 5 using a 10% CHE threshold). The risk of CHE would be higher for a few disease areas, including cardiovascular disease and mental/behavioral disorders (7.8% and 9.8% using a 10% CHE threshold), while lower risks of CHE were observed for lower cost services. CONCLUSIONS Insufficient FRP stands as a major barrier to achieving UHC, and risk of CHE is a major problem for health systems in low-income and lower-middle-income countries. Beyond its threat to the financial stability of households, CHE may also lead to worse health outcomes, especially among the poorest for whom both ill health and financial risk are most severe. Modeling the risk of CHE associated with specific disease areas and services can help policymakers set progressive health sector priorities. Decision-makers could explicitly include FRP as a criterion for consideration when assessing the health interventions for inclusion in national essential benefit packages.
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Affiliation(s)
- Sarah Bolongaita
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
- Department of Global Public Health and Primary Care, University of Bergen, Pb. 7804, NO-5020, Bergen, Norway
| | - Yeeun Lee
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Kjell Arne Johansson
- Department of Global Public Health and Primary Care, University of Bergen, Pb. 7804, NO-5020, Bergen, Norway
| | - Øystein A Haaland
- Department of Global Public Health and Primary Care, University of Bergen, Pb. 7804, NO-5020, Bergen, Norway
| | - Mieraf Taddesse Tolla
- Addis Center for Ethics and Priority Setting, Addis Ababa University, Addis Ababa, Ethiopia
- Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Jongwook Lee
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
- Department of Agricultural Economics and Rural Development, Seoul National University, Seoul, South Korea
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.
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Ajayi AI, Ahinkorah BO, Seidu AA. "I don't like to be seen by a male provider": health workers' strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria. Int Health 2023; 15:435-444. [PMID: 36167330 PMCID: PMC10318974 DOI: 10.1093/inthealth/ihac064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/10/2022] [Accepted: 09/18/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ending maternal mortality has been a significant global health priority for decades. Many sub-Saharan African countries introduced user fee removal policies to attain this goal and ensure universal access to health facility delivery. However, many women in Nigeria continue to deliver at home. We examined the reasons for home birth in settings with free maternal healthcare in Southwestern and North Central Nigeria. METHODS We adopted a fully mixed, sequential, equal-status design. For the quantitative study, we drew data from 211 women who reported giving birth at home from a survey of 1227 women of reproductive age who gave birth in the 5 y before the survey. The qualitative study involved six focus group discussions and 68 in-depth interviews. Data generated through the interviews were coded and subjected to inductive thematic analysis, while descriptive statistics were used to analyse the quantitative data. RESULTS Women faced several barriers that limited their use of skilled birth attendants. These barriers operate at multiple levels and could be grouped as economic, sociocultural and health facility-related factors. Despite the user fee removal policy, lack of transportation, birth unpreparedness and lack of money pushed women to give birth at home. Also, sociocultural reasons such as hospital delivery not being deemed necessary in the community, women not wanting to be seen by male health workers, husbands not motivated and husbands' disapproval hindered the use of health facilities for childbirth. CONCLUSIONS This study has demonstrated that free healthcare does not guarantee universal access to healthcare. Interventions, especially in the Nasarawa state of Nigeria, should focus on the education of mothers on the importance of health facility-based delivery and birth preparedness.
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Affiliation(s)
- Anthony Idowu Ajayi
- Sexual, Reproductive, Maternal, New-born, Child and Adolescent Health (SRMNCAH) Unit, African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Bright Opoku Ahinkorah
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Abdul-Aziz Seidu
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Australia
- Centre for Gender and Advocacy, Takoradi Technical University, Takoradi, Ghana
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Ilboudo PG, Siri A. Effects of the free healthcare policy on maternal and child health in Burkina Faso: a nationwide evaluation using interrupted time-series analysis. HEALTH ECONOMICS REVIEW 2023; 13:27. [PMID: 37145306 PMCID: PMC10161454 DOI: 10.1186/s13561-023-00443-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Burkina Faso has recently instituted a free healthcare policy for women and children under five. This comprehensive study examined the effects of this policy on the use of services, health outcomes, and removal of costs. METHODS Interrupted time-series regressions were used to investigate the effects of the policy on the use of health services and health outcomes. In addition, an analysis of household expenditures was conducted to assess the effects of spending on delivery, care for children, and other exempted (antenatal, postnatal, etc.) services on household expenditures. RESULTS The findings show that the user fee removal policy significantly increased the use of healthcare facilities for child consultations and reduced mortality from severe malaria in children under the age of five years. It also has increased the use of health facilities for assisted deliveries, complicated deliveries, and second antenatal visits, and reduced cesarean deliveries and intrahospital infant mortality, although not significantly. While the policy has failed to remove all costs, it decreased household costs to some extent. In addition, the effects of the user fee removal policy seemed higher in districts with non-compromised security for most of the studied indicators. CONCLUSIONS Given the positive effects, the findings of this investigation support the pursuit of implementing the free healthcare policy for maternal and child care.
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Affiliation(s)
| | - Alain Siri
- Secrétariat Permanent du Plan National de Développement Economique et Social (SP/PNDES), Ouagadougou, Burkina Faso
- Institut des Sciences des Sociétés, Ouagadougou, Burkina Faso
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Odoch WD, Senkubuge F, Masese AB, Hongoro C. A critical review of literature on health financing reforms in Uganda - progress, challenges and opportunities for achieving UHC. Afr Health Sci 2023; 23:736-746. [PMID: 37545949 PMCID: PMC10398427 DOI: 10.4314/ahs.v23i1.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Background Universal health coverage (UHC) is one of the sustainable development goals (SDG) targets. Progress towards UHC necessitates health financing reforms in many countries. Uganda has had reforms in its health financing, however, there has been no examination of how the reforms align with the principles of financing for UHC. Objective This review examines how health financing reforms in Uganda align with UHC principles and contribute to ongoing discussions on financing UHC. Methods We conducted a critical review of literature and utilized thematic framework for analysis. Results are presented narratively. The analysis focused on health financing during four health sector strategic plan (HSSP) periods. Results In HSSP I, the focus of health financing was on equity, while in HSSP II the focus was on mobilizing more funding. In HSSP III & IV the focus was on financial risk protection and UHC. The changes in focus in health financing objectives have been informed by low per capita expenditures, global level discussions on SDGs and UHC, and the ongoing health financing reform discussions. User fees was abolished in 2001, sector-wide approach was implemented during HSSP I&II, and pilots with results-based financing have occurred. These financing initiatives have not led to significant improvements in financial risk protection as indicated by the high out-of-pocket payments. Conclusion Health financing policy intentions were aligned with WHO guidance on reforms towards UHC, however actual outputs and outcomes in terms of improvement in health financing functions and financial risk protections remain far from the intentions.
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Affiliation(s)
- Walter Denis Odoch
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa
- Afya Research and Development Institute, P.O. Box 21743, Plot 2703, Block 208, Bombo Rd, Kampala, Uganda
- East, Central and Southern Africa Health Community P.O. Box 1009, Arusha Tanzania
| | - Flavia Senkubuge
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa
| | - Ann Bosibori Masese
- Afya Research and Development Institute, P.O. Box 21743, Plot 2703, Block 208, Bombo Rd, Kampala, Uganda
- Centre for Health Solutions Kenya
| | - Charles Hongoro
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa
- Developmental, Capable and Ethical State (DCE) Division, Human Sciences Research Council of South Africa Private Bag X41, Pretoria, 0001, South Africa
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Xu M, Bittschi B. Does the abolition of copayment increase ambulatory care utilization?: a quasi-experimental study in Germany. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1319-1328. [PMID: 35084631 DOI: 10.1007/s10198-022-01430-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/06/2022] [Indexed: 06/14/2023]
Abstract
Due to a problematic situation with public finances, Germany introduced a copayment scheme for ambulatory care visits in 2004. In 2012, Germany achieved a balanced budget, and copayment was abolished on the 1st of January 2013. This policy change offers a rare opportunity to explore the impact of the abolition of copayment, compared to the much more frequently studied introduction of copayment. We therefore investigate the development of ambulatory care and inpatient care utilization following this policy change among people over 50 in Germany, as well as the heterogeneous impacts among vulnerable people, such as the low-income population, the chronically ill and the elderly over the age of 65. We use data from the Survey of Health, Ageing and Retirement in Europe and adopt a difference-in-differences approach with matching. We found that the abolition of copayment only caused an increase in ambulatory care use in the shorter term, while leading to a significant reduction in the longer term. In addition, we find a negative effect on inpatient care use, i.e., the hospitalization offset effect. Finally, we demonstrate that vulnerable people were more sensitive to the abolition of copayment.
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Affiliation(s)
- Mingming Xu
- School of Public Health (Shenzhen), Sun Yat-sen University, Gongchang Road 66, Shenzhen, 518107, China.
- Department of Economics and Management, Karlsruhe Institute of Technology, Kronenstraβe 34, 76133, Karlsruhe, Germany.
| | - Benjamin Bittschi
- Austrian Institute of Economic Research (WIFO), Arsenal, Objekt 20, 1030, Vienna, Austria
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Eze P, Lawani LO, Agu UJ, Amara LU, Okorie CA, Acharya Y. Factors associated with catastrophic health expenditure in sub-Saharan Africa: A systematic review. PLoS One 2022; 17:e0276266. [PMID: 36264930 PMCID: PMC9584403 DOI: 10.1371/journal.pone.0276266] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/04/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE A non-negligible proportion of sub-Saharan African (SSA) households experience catastrophic costs accessing healthcare. This study aimed to systematically review the existing evidence to identify factors associated with catastrophic health expenditure (CHE) incidence in the region. METHODS We searched PubMed, CINAHL, Scopus, CNKI, Africa Journal Online, SciELO, PsycINFO, and Web of Science, and supplemented these with search of grey literature, pre-publication server deposits, Google Scholar®, and citation tracking of included studies. We assessed methodological quality of included studies using the Appraisal tool for Cross-Sectional Studies for quantitative studies and the Critical Appraisal Skills Programme checklist for qualitative studies; and synthesized study findings according to the guidelines of the Economic and Social Research Council. RESULTS We identified 82 quantitative, 3 qualitative, and 4 mixed-methods studies involving 3,112,322 individuals in 650,297 households in 29 SSA countries. Overall, we identified 29 population-level and 38 disease-specific factors associated with CHE incidence in the region. Significant population-level CHE-associated factors were rural residence, poor socioeconomic status, absent health insurance, large household size, unemployed household head, advanced age (elderly), hospitalization, chronic illness, utilization of specialist healthcare, and utilization of private healthcare providers. Significant distinct disease-specific factors were disability in a household member for NCDs; severe malaria, blood transfusion, neonatal intensive care, and distant facilities for maternal and child health services; emergency surgery for surgery/trauma patients; and low CD4-count, HIV and TB co-infection, and extra-pulmonary TB for HIV/TB patients. CONCLUSIONS Multiple household and health system level factors need to be addressed to improve financial risk protection and healthcare access and utilization in SSA. PROTOCOL REGISTRATION PROSPERO CRD42021274830.
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Affiliation(s)
- Paul Eze
- Department of Health Policy and Administration, Pennsylvania State University, University Park, PA, United States of America
- * E-mail:
| | - Lucky Osaheni Lawani
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Ujunwa Justina Agu
- Department of Community Medicine, Enugu State University Teaching Hospital, Parklane, Enugu, Nigeria
| | - Linda Uzo Amara
- Department of Community Medicine, Enugu State University Teaching Hospital, Parklane, Enugu, Nigeria
| | - Cassandra Anurika Okorie
- Department of Community Medicine, Ebonyi State University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - Yubraj Acharya
- Department of Health Policy and Administration, Pennsylvania State University, University Park, PA, United States of America
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Damte Tegegn B, Negeri KG. Assessment of utilization of health care services and the associated factors among adult fee-waiver beneficiaries in Hawassa, southern Ethiopia: A community based cross sectional study. J Public Health Res 2022; 11:22799036221139940. [DOI: 10.1177/22799036221139940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/02/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Over the past decades, developing countries like Ethiopia have resorted to the implementation of user fees in public health care systems. Nonetheless, evidences suggest that user fees affect the poor negatively. Therefore, Ethiopian government introduced fee-waiver mechanism in 1998 aiming to mitigate the financial constraints faced by the poorest segment of the population in utilizing health care services. Yet, in the country, there is limited evidence on this subject. Objective: The overall objective of the study was to assess health care utilization and the associated factors among the fee-waiver beneficiaries in Hawassa City of Southern Ethiopia. Methodology: A quantitative, cross-sectional study design was employed using a sample of 636 fee-waiver beneficiaries. Data was collected using a structured interviewer-administered questionnaire and analyzed using binary logistic regression. An odds ratio with the corresponding CI was used to identify the associated factors, while P < 0.05 was used to declare significance. Results: The response rate to the survey is 581(91.4%). Of this, 377 (65%) utilized health services in the preceding 3 months of data collection. Availability of medical equipment [AOR = 1.501; 95% C.I. (1.066–2.114)], being >50 years of age [AOR = 2.271; 95% C.I. (1.304–3.953)], improved drug availability in the health care facilities [AOR = 1.682; 95% C.I. (1.118–2.530)] and beneficiaries’ perception of health worker’s handling practice [AOR = 3.759; 95% C.I. (1.425–9.912)] were among the significant factors associated with beneficiaries’ utilization of health care services at public health facilities. Conclusion and recommendation: The overall fee waiver beneficiaries’ health care utilizations rate is 64.9%. Optimizing availability of medical equipment, enhancing drug availability and strengthening good patient handling practices are recommended.
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Affiliation(s)
- Biruk Damte Tegegn
- Health financing improvement Program, Abt Associates Inc, Hawassa, Ethiopia
| | - Keneni Gutema Negeri
- School of Public Health, Health Systems Management and Policy Unit, Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
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Nannini M, Biggeri M, Putoto G. Health Coverage and Financial Protection in Uganda: A Political Economy Perspective. Int J Health Policy Manag 2022; 11:1894-1904. [PMID: 34634869 PMCID: PMC9808243 DOI: 10.34172/ijhpm.2021.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/23/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition. METHODS The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector. RESULTS We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship. CONCLUSION By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.
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Affiliation(s)
- Maria Nannini
- Department of Economics and Management, University of Florence, Florence, Italy
| | - Mario Biggeri
- Department of Economics and Management, University of Florence, Florence, Italy
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Kitole FA, Lihawa RM, Mkuna E. Comparative Analysis on Communicable and Non-Communicable Diseases on Catastrophic Spending and Impoverishment in Tanzania. GLOBAL SOCIAL WELFARE : RESEARCH, POLICY & PRACTICE 2022:1-12. [PMID: 36043157 PMCID: PMC9412805 DOI: 10.1007/s40609-022-00241-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 05/23/2023]
Abstract
The question of whether communicable or non-communicable diseases have higher economic effects on households is rarely explored from the global to local level despite of their significant contribution in increasing household catastrophic spending and impoverishment. To shed light into this, therefore, this paper comparatively examines the economic effects of communicable and non-communicable diseases in Tanzania by the use of Tanzania Panel Survey data of 2019/2020 which has been used to analyze different parameters to provide needful information. The empirical analysis employed probit, two-stage residual inclusion (2SRI), and control function approachf (CFA) helpful in controlling endogeneity issues. Findings showed that, comparatively, non-communicable diseases have higher economic effects in endangering households into catastrophic spending and impoverishment comparing to communicable diseases. Conclusively, neglecting developing countries to fights against multiplicative effects of these diseases alone will result in killing their economies since most of these countries depend on donors and household as a means of healthcare financing. However, this paper recommends for global initiatives in reducing the burden of disease by funding on palliative care costs and enhancing the availability of affordable health insurance schemes to reduce household economic burden.
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Affiliation(s)
| | | | - Eliaza Mkuna
- Department of Economics, Mzumbe University, P.O. Box 5, Morogoro, Tanzania
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14
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Adeniji FIP, Lawanson AO, Osungbade KO. The microeconomic impact of out-of-pocket medical expenditure on the households of cardiovascular disease patients in general and specialized heart hospitals in Ibadan, Nigeria. PLoS One 2022; 17:e0271568. [PMID: 35849602 PMCID: PMC9292125 DOI: 10.1371/journal.pone.0271568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 07/03/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Cardiovascular diseases (CVDs) present a huge threat to population health and in addition impose severe economic burden on individuals and their households. Despite this, there is no research evidence on the microeconomic impact of CVDs in Nigeria. Therefore, this study estimated the incidence and intensity of catastrophic health expenditures (CHE), poverty headcount due to out-of-pocket (OOP) medical spending and the associated factors among the households of a cohort of CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan, Nigeria.
Methods
This study adopts a descriptive cross-sectional study design. A standardized data collection questionnaire developed by the Initiative for Cardiovascular Health Research in Developing Countries was adapted to electronically collect data from all the 744 CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan between 4th November 2019 to the 31st January 2020. A sensitivity analysis, using rank-dependent thresholds of CHE which ranged from 5%-40% of household total expenditures was carried out. The international poverty line of $1.90/day recommended by the World Bank was utilized to ascertain poverty headcounts pre-and post OOP payments for healthcare services. Categorical variables like household socio-demographic and clinical characteristics, CHE and poverty headcounts, were presented using percentages and proportions. Unadjusted and adjusted logistic regression models were used to assess the factors associated with CHE and poverty. Data were analyzed using STATA version 15 and estimates were validated at 5% level of significance.
Results
Catastrophic OOP payment ranged between 3.9%-54.6% and catastrophic overshoot ranged from 1.8% to 12.6%. Health expenditures doubled poverty headcount among households, from 8.13% to 16.4%. Having tertiary education (AOR: 0.49, CI: 0.26–0.93, p = 0.03) and household size (AOR: 0.40, CI: 0.24–0.67, p = 0.001) were significantly associated with CHE. Being female (AOR: 0.41, CI: 0.18–0.92, p = 0.03), household economic status (AOR: 0.003, CI: 0.0003–0.25, p = <0.001) and having 3–4 household members (AOR: 0.30, CI: 0.15–0.61, p = 0.001) were significantly associated with household poverty status post payment for medical services.
Conclusion
OOP medical spending due to CVDs imposed enormous strain on household resources and increased the poverty rates among households. Policies and interventions that supports universal health coverage are highly recommended.
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Affiliation(s)
- Folashayo Ikenna Peter Adeniji
- Department of Health Policy & Management, College of Medicine, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria
- * E-mail:
| | - Akanni Olayinka Lawanson
- Department of Economics, Faculty of Economics & Management Sciences, University of Ibadan, Ibadan, Nigeria
| | - Kayode Omoniyi Osungbade
- Department of Health Policy & Management, College of Medicine, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria
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Jung H, Lee KS. What Policy Approaches Were Effective in Reducing Catastrophic Health Expenditure? A Systematic Review of Studies from Multiple Countries. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:525-541. [PMID: 35285001 DOI: 10.1007/s40258-022-00727-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The United Nations set a goal for universal health coverage in all countries by 2030 and selected the catastrophic health expenditure (CHE) indicator as an assessment tool for this goal. Many countries have strived to reduce household CHE. However, no study has compared countries whose policies have had a remarkable effect on decreasing CHE. Therefore, the purpose of this systematic literature review is to find appropriate methods for measuring CHE that can help us to analyze the impact of health policies and identify countries whose health policies are most effective in reducing CHE. METHOD PubMed and Web of Science were searched. Studies that measured the incidence or intensity of CHE in multiple years were included. Two independent reviewers screened the literature, extracted the data, and analyzed the studies selected. Thirty-eight studies met the inclusion criteria for the review. We classified the selected research papers to random sampling and quasi-experimental studies. RESULTS We graphically presented the results of CHE incidence and intensity rates reported in the collected papers as a time series data set. Since most studies did not use sample weights, it was not easy to confirm whether the time series changes of CHE are significant. Therefore, we could find only two countries that had policy effects. Both countries established policies that focus on the poor. CONCLUSION There are so many studies that analyze CHE, but policies that are effective in reducing CHE are unknown. This study uses a systematic literature review methodology to determine effective policies by comparing CHE time series trends among countries. As a policy implication, it was found that because CHE is defined as the ratio of the ability to pay to medical expenses, a policy of differential medical expenses that is based on income level is effective.
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Affiliation(s)
- HyunWoo Jung
- Department of Health Administration, Graduate School·BK21 Graduate Program of Developing Glocal Experts in Health Policy and Management, Yonsei University, Changjo Hall, Room Number 419, Yonseidaegil 1, Gangwon-do, Wonju, South Korea
| | - Kwang-Soo Lee
- Department of Health Administration, Graduate School·BK21 Graduate Program of Developing Glocal Experts in Health Policy and Management, Yonsei University, Changjo Hall, Room Number 419, Yonseidaegil 1, Gangwon-do, Wonju, South Korea.
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16
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Eze P, Lawani LO, Agu UJ, Acharya Y. Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis. Bull World Health Organ 2022; 100:337-351J. [PMID: 35521041 PMCID: PMC9047424 DOI: 10.2471/blt.21.287673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa. Methods We systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model. Findings We identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9-20.4; 50 datapoints; 462 151 households; I 2 = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2-10.3; 84 datapoints; 795 355 households; I 2 = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher. Conclusion Although data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.
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Affiliation(s)
- Paul Eze
- Department of Health Policy and Administration, 504A Donald H. Ford Building, Pennsylvania State University, University Park, Pennsylvania, PA 16802, United States of America
| | - Lucky Osaheni Lawani
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Ujunwa Justina Agu
- Department of Community Medicine, Enugu State University Teaching Hospital, Parklane, Nigeria
| | - Yubraj Acharya
- Department of Health Policy and Administration, 504A Donald H. Ford Building, Pennsylvania State University, University Park, Pennsylvania, PA 16802, United States of America
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17
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Lindberg C, Nareeba T, Kajungu D, Hirose A. The Extent of Universal Health Coverage for Maternal Health Services in Eastern Uganda: A Cross Sectional Study. Matern Child Health J 2021; 26:632-641. [PMID: 34967928 PMCID: PMC8917020 DOI: 10.1007/s10995-021-03357-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 11/29/2022]
Abstract
Objective Monitoring essential health services coverage is important to inform resource allocation for the attainment of the Sustainable Development Goal 3. The objective was to assess service, effective and financial coverages of maternal healthcare services and their equity, using health and demographic surveillance site data in eastern Uganda. Methods Between Nov 2018 and Feb 2019, 638 resident women giving birth in 2017 were surveyed. Among them, 386 were randomly sampled in a follow-up survey (Feb 2019) on pregnancy and delivery payments and contents of care. Service coverage (antenatal care visits, skilled birth attendance, institutional delivery and one postnatal visit), effective coverage (antenatal and postnatal care content) and financial coverage (out-of-pocket payments for antenatal and delivery care and health insurance coverage) were measured, stratified by socio-economic status, education level and place of residence. Results Coverage of skilled birth attendance and institutional delivery was both high (88%), while coverage of postnatal visit was low (51%). Effective antenatal care was lower than effective postnatal care (38% vs 76%). Financial coverage was low: 91% of women made out-of-pocket payments for delivery services. Equity analysis showed coverage of institutional delivery was higher for wealthier and peri-urban women and these women made higher out-of-pocket payments. In contrast, coverage of a postnatal visit was higher for rural women and poorest women. Conclusion Maternal health coverage in eastern Uganda is not universal and particularly low for postnatal visit, effective antenatal care and financial coverage. Analysing healthcare payments and quality by healthcare provider sector is potential future research. Supplementary Information The online version contains supplementary material available at 10.1007/s10995-021-03357-3.
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Affiliation(s)
- Clara Lindberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, 171 77, Stockholm, Sweden
| | - Tryphena Nareeba
- Demographic Surveillance Site, Centre for Public Health and Population Research, Makerere University, New Mulago Hill Road, Mulago, Kampala, Uganda
| | - Dan Kajungu
- Centre for Health and Population Research, Makerere University, New Mulago Hill Road, Mulago, Kampala, Uganda.,Iganga/Mayuge Health and Demographic Surveillance Site, Kampala, Uganda
| | - Atsumi Hirose
- School of Public Health, Imperial College London, London, UK. .,Department of Global Public Health, Karolinska Institute, 171 77, Stockholm, Sweden.
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Arunda MO, Agardh A, Asamoah BO. Determinants of continued maternal care seeking during pregnancy, birth and postnatal and associated neonatal survival outcomes in Kenya and Uganda: analysis of cross-sectional, demographic and health surveys data. BMJ Open 2021; 11:e054136. [PMID: 34903549 PMCID: PMC8672021 DOI: 10.1136/bmjopen-2021-054136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To examine how maternal and sociodemographic factors determine continued care-seeking behaviour from pregnancy to postnatal period in Kenya and Uganda and to determine associated neonatal survival outcomes. DESIGN A population-based analysis of cross-sectional data using multinomial and binary logistic regressions. SETTING Countrywide, Kenya and Uganda. PARTICIPANTS Most recent live births of 24 502 mothers within 1-59 months prior to the 2014-2016 Demographic and Health Surveys. OUTCOMES Care-seeking continuum and neonatal mortality. RESULTS Overall, 57% of the mothers had four or more antenatal care (ANC) contacts, of which 73% and 41% had facility births and postnatal care (PNC), respectively. Maternal/paternal education versus no education was associated with continued care seeking in majority of care-seeking classes; relative risk ratios (RRRs) ranged from 2.1 to 8.0 (95% CI 1.1 to 16.3). Similarly, exposure to mass media was generally associated with continued care seekin; RRRs ranged from 1.8 to 3.2 (95% CI 1.2 to 5.4). Care-seeking tendency reduced if a husband made major maternal care-seeking decisions. Transportation problems and living in rural versus urban were largely associated with lower continued care use; RRR ranged from 0.4 to 0.7 (95% CI 0.3 to 0.9). The two lowest care-seeking categories with no ANC and no PNC indicated the highest odds for neonatal mortality (adjusted OR 4.2, 95% CI 1.6 to 10.9). 23% neonatal deaths were attributable to inadequate maternal care attendance. CONCLUSION Strategies such as mobile health specifically for promoting continued maternal care use up to postnatal could be integrated in the existing structures. Another strategy would be to develop and employ a brief standard questionnaire to determine a mother's continued care-seeking level during the first ANC visit and to use the information to close the care-seeking gaps. Strengthening the community health workers system to be an integral part of promoting continued care seeking could enhance care seeking as a stand-alone strategy or as a component of aforementioned suggested strategies.
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Affiliation(s)
- Malachi Ochieng Arunda
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anette Agardh
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Benedict Oppong Asamoah
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
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Srivastava S, Kumar P, Chauhan S, Banerjee A. Household expenditure for immunization among children in India: a two-part model approach. BMC Health Serv Res 2021; 21:1001. [PMID: 34551769 PMCID: PMC8459463 DOI: 10.1186/s12913-021-07011-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 09/10/2021] [Indexed: 01/12/2023] Open
Abstract
Background Despite the Indian government’s Universal Immunization Program (UIP), the progress of full immunization coverage is plodding. The cost of delivering routine immunization varies widely across facilities within country and across country. However, the cost an individual bears on child immunization has not been focussed. In this context, this study tries to estimate the expenditure on immunization which an individual bears and the factors affecting immunization coverage at the regional level. Methods Using the 75th round of National Sample Survey Organization data, the present paper attempts to check the individual expenditure on immunization and the factors affecting immunization coverage at the regional level. Descriptive statistics and multivariate regression analysis were used to fulfil the study objectives. The two-part model has been employed to inspect the determinants of expenditure on immunization. Results The overall prevalence of full immunization was 59.3 % in India. Full immunization was highest in Manipur (75.2 %) and lowest in Nagaland (12.8 %). The mean expenditure incurred on immunization varies from as low as Rs. 32.7 in Tripura to as high as Rs. 1008 in Delhi. Children belonging to the urban area [OR: 1.04; CI: 1.035, 1.037] and richer wealth quintile [OR: 1.14; CI: 1.134–1.137] had higher odds of getting immunization. Moreover, expenditure on immunization was high among children from the urban area [Rs. 273], rich wealth quintile [Rs. 297] and who got immunized in a private facility [Rs. 1656]. Conclusions There exists regional inequality in immunization coverage as well as in expenditure incurred on immunization. Based on the findings, we suggest looking for the supply through follow-up and demand through spreading awareness through mass media for immunization. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07011-0.
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Affiliation(s)
- Shobhit Srivastava
- Department of Mathematical Demography & Statistics, International Institute for Population Sciences, Mumbai, India
| | - Pradeep Kumar
- Department of Mathematical Demography & Statistics, International Institute for Population Sciences, Mumbai, India.
| | - Shekhar Chauhan
- Department of Population Policies and Programmes, International Institute for Population Sciences, Mumbai, India
| | - Adrita Banerjee
- Department of Public Health and Mortality Studies, International Institute for Population Sciences, Mumbai, India
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20
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Obembe TA, Levin J, Fonn S. Prevalence and factors associated with catastrophic health expenditure among slum and non-slum dwellers undergoing emergency surgery in a metropolitan area of South Western Nigeria. PLoS One 2021; 16:e0255354. [PMID: 34464387 PMCID: PMC8407567 DOI: 10.1371/journal.pone.0255354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 07/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Out of Pocket (OOP) payment continues to persist as the major mode of payment for healthcare in Nigeria despite the introduction of the National Health Insurance Scheme (NHIS). Although the burden of health expenditure has been examined in some populations, the impact of OOP among slum dwellers in Nigeria when undergoing emergencies, is under-researched. This study sought to examine the prevalence, factors and predictors of catastrophic health expenditure amongst selected slum and non-slum communities undergoing emergency surgery in Southwestern Nigeria. METHODS The study utilised a descriptive cross-sectional survey design to recruit 450 households through a multistage sampling technique. Data were collected using pre-tested semi-structured questionnaires in 2017. Factors considered for analysis relating to the payer were age, sex, relationship of payer to patient, educational status, marital status, ethnicity, occupation, income and health insurance coverage. Variables factored into analysis for the patient were indication for surgery, grade of hospital, and type of hospital. Households were classified as incurring catastrophic health expenditure (CHE), if their OOP expenditure exceeded 5% of payers' household budget. Analysis of the data took into account the multistage sampling design. RESULTS Overall, 65.6% (95% CI: 55.6-74.5) of the total population that were admitted for emergency surgery, experienced catastrophic expenditure. The prevalence of catastrophic expenditure at 5% threshold, among the population scheduled for emergency surgeries, was significantly higher for slum dwellers (74.1%) than for non-slum dwellers (47.7%) (F = 8.59; p = 0.019). Multiple logistic regression models revealed the significant independent factors of catastrophic expenditure at the 5% CHE threshold to include setting of the payer (whether slum or non-slum dweller) (p = 0.019), and health insurance coverage of the payer (p = 0.012). Other variables were nonetheless significant in the bivariate analysis were age of the payer (p = 0.017), income (p<0.001) and marital status of the payer (p = 0.022). CONCLUSION Although catastrophic health expenditure was higher among the slum dwellers, substantial proportions of respondents incurred catastrophic health expenditure irrespective of whether they were slum or non-slum dwellers. Concerted efforts are required to implement protective measures against catastrophic health expenditure in Nigeria that also cater to slum dwellers.
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Affiliation(s)
- Taiwo A. Obembe
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- Department of Health Policy and Management, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Jonathan Levin
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Sharon Fonn
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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21
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Eozenou PHV, Neelsen S, Smitz MF. Financial Protection in Health among the Elderly - A Global Stocktake. Health Syst Reform 2021; 7:e1911067. [PMID: 34402386 DOI: 10.1080/23288604.2021.1911067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Universal Health Coverage is one of the key targets of the Sustainable Development Goals and it implies that everyone can access the healthcare they need without suffering financial hardship. In this paper, we use a large set of household surveys to examine if older populations are facing different degrees of financial hardship compared to younger populations. We find that while differences in average age structures between countries are not systematically associated with higher financial risk related to out-of-pocket health expenditures, there are large differences in financial hardship between younger and older households within countries. Households with more elderly members are more likely to face catastrophic and impoverishing out-of-pocket health payments compared to younger households, and this age gradient is stronger for the poorest segments of the population. Making progress toward Universal Health Coverage will require extension and improved targeting of benefit packages and financial protection to meet the health needs of older adults, and especially the poorest and most vulnerable segments of elderly populations.
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Affiliation(s)
| | - Sven Neelsen
- Health, Nutrition, and Population Unit, The World Bank, Washington, DC, USA
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22
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Bapolisi WA, Karemere H, Ndogozi F, Cikomola A, Kasongo G, Ntambwe A, Bisimwa G. First recourse for care-seeking and associated factors among rural populations in the eastern Democratic Republic of the Congo. BMC Public Health 2021; 21:1367. [PMID: 34246245 PMCID: PMC8272345 DOI: 10.1186/s12889-021-11313-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/18/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Access to quality healthcare is a global fundamental human right. However, in the Democratic Republic of the Congo, several parameters affect the choices of health service users in fragile, rural contexts (zones). The overarching aim of this study was to identify the first recourse of healthcare-seeking and the determinants of utilization of health centers (primary health care structures) in the rural health zones of Katana and Walungu. METHODS A cross-sectional survey was conducted from June to September 2017. Consenting respondents comprised 1751 adults. Continuous data were summarized using means (standard deviation) and medians (interquartile range). We used Pearson's chi-square test and Fisher exact test to compare proportions. Logistic regression was run to assess socio-determinants of health center utilization. RESULTS The morbidity rate of the sample population for the previous month was 86.4% (n = 1501) of which 60% used health centers for their last morbid episode and 20% did not. 5.3% of the respondents patronized prayer rooms and 7.9% resorted to self-medication principally because the cost was low, or the services were fast. Being female (OR: 1.51; p = 0.005) and a higher level of education (OR: 1.79; p = 0.032) were determinants of the use of health centers in Walungu. Only the level of education was associated with the use of health centers in Katana (OR: 2.78; p = 0.045). CONCLUSION Our findings suggest that health centers are the first recourse for the majority of the population during an illness. However, a significant percentage of patients are still using traditional healers or prayer rooms because the cost is low. Our results suggest that future interventions to encourage integrated health service use should target those with lower levels of education.
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Affiliation(s)
- Wyvine Ansima Bapolisi
- Ecole Régionale de Santé Publique de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo.
| | - Hermès Karemere
- Ecole Régionale de Santé Publique de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Freddy Ndogozi
- Division provincial de la Santé du Sud-Kivu, Bukavu, Democratic Republic of the Congo
| | - Aimé Cikomola
- Ecole Régionale de Santé Publique de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo.,Division provincial de la Santé du Sud-Kivu, Bukavu, Democratic Republic of the Congo.,Programme RIPSEC (Renforcement Institutionnel des Institutions pour les Politiques de santé basées sur l'évidence en République Démocratique du Congo), Lubumbashi, Democratic Republic of the Congo
| | - Ghislain Kasongo
- Bureau central de la zone de santé de Walungu, Walungu, Democratic Republic of the Congo
| | - Albert Ntambwe
- Programme RIPSEC (Renforcement Institutionnel des Institutions pour les Politiques de santé basées sur l'évidence en République Démocratique du Congo), Lubumbashi, Democratic Republic of the Congo.,Ecole de santé Publique de l'Université de Lubumbashi, Lubumbashi, Democratic Republic of the Congo
| | - Ghislain Bisimwa
- Ecole Régionale de Santé Publique de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo.,Programme RIPSEC (Renforcement Institutionnel des Institutions pour les Politiques de santé basées sur l'évidence en République Démocratique du Congo), Lubumbashi, Democratic Republic of the Congo
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Measurement and determinants of financial protection in health in Afghanistan. BMC Health Serv Res 2021; 21:650. [PMID: 34218808 PMCID: PMC8254857 DOI: 10.1186/s12913-021-06613-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/07/2021] [Indexed: 11/20/2022] Open
Abstract
Background Out of pocket (OOP) payments for health are significant health financing challenges in Afghanistan as it is a source of incurrence of catastrophic health expenditure (CHE) and impoverishment. Measuring and understanding the drivers and impacts of this financial health hardship is an economic and public health priority, particularly in the time of COVID-19. This is the first study that measures the financial hardship and determines associated factors in Afghanistan. Methods Afghanistan Living Conditions Survey data for 2016–2017 was used for this study. We calculated incidence and intensity of catastrophic health expenditure by using different thresholds ranging from 5 to 40% of total and nonfood consumption and subsequent impoverishment due to OOPs. Logistic regression was used to assess the degree to which Afghan households are protected from the catastrophic household expenditure. Results Results revealed that 32% of the population in Afghanistan incurred catastrophic health expenditure (as 10% of total consumption) and when healthcare payments are netted out of household consumption, the Afghan population live in extreme poverty ($1.9 in 2011 PPP), increased from 29 to 36%. Based on our findings from logistic regression in Afghanistan, having an educated head or being employed are protective factors from financial hardship while having a female head, an elderly member, a disabled, or a sick member are the risk factors of facing catastrophic health expenditure. Moreover, the people living in rural/nomadic areas or facing an economic shock are more likely to face catastrophic health expenditure and hence to be impoverished due to direct OOPs on health. Conclusions The high rate of poverty and catastrophic health expenditure in Afghanistan emphasizes the need to strengthen the health financing system. Although Afghanistan has made great efforts to support households against health expenditure burden during the pandemic, households are at higher risk of poverty and financial hardship due to OOPs. Therefore, there is need for more financial and supportive response policies by providing a better and easier access to primary health services, extending to all entitlement to health services particularly in the public sector, eliminating user fees for COVID-19 health services and suspending fees for other essential health services, expanding coverage of income support, and strengthening the overall health financing system.
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Angèle MN, Abel NM, Jacques OM, Henri MT, Françoise MK. Social and economic consequences of the cost of obstetric and neonatal care in Lubumbashi, Democratic Republic of Congo: a mixed methods study. BMC Pregnancy Childbirth 2021; 21:315. [PMID: 33882894 PMCID: PMC8059173 DOI: 10.1186/s12884-021-03765-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to explore and measure the social and economic consequences of the costs of obstetric and neonatal care in Lubumbashi, the Democratic Republic of Congo. Methods We conducted a mixed qualitative and quantitative study in the maternity departments of health facilities in Lubumbashi. The qualitative results were based on a case study conducted in 2018 that included 14 respondents (8 mothers of newborns, 2 accompanying family members and 4 health care providers). A quantitative cross-sectional analytical study was carried out in 2019 with 411 women who gave birth at 10 referral hospitals. Data were collected for one month at each hospital, and selected mothers of newborns were included in the study only if they paid out-of-pocket and at the point of care for costs related to obstetric and neonatal care. Results Costs for obstetric and neonatal care averaged US $77, US $207 and US $338 for simple, complicated vaginal and caesarean deliveries, respectively. These health expenditures were greater than or equal to 40% of the ability to pay for 58.4% of households. At the time of delivery, 14.1% of women giving birth did not have enough money to pay for care. Of those who did, 76.5% spent their savings. When households did not pay for care, mothers and their babies were held for a long time at the place of care. This resulted in the prolonged absence of the mother from the household, reduced household income, family conflicts, and the abandonment of the home by the spouse. At the health facility level, the increase in length of stay did not generate any additional financial benefits. Mothers no longer had confidence in nurses; they were sometimes separated from their babies, and they could not access certain prescribed medications or treatments. Conclusion The government of the DRC should implement a mechanism for subsidizing care and associate it with a cost-sharing system. This would place the country on the path to achieving universal health coverage in improving the physical, mental and social health of mothers, their babies and their households. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03765-x.
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Affiliation(s)
- Musau Nkola Angèle
- School of Public Health, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo.
| | | | | | - Mundongo Tshamba Henri
- School of Public Health, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Malonga Kaj Françoise
- School of Public Health, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
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Hasan MZ, Mehdi GG, De Broucker G, Ahmed S, Ali MW, Martin Del Campo J, Constenla D, Patenaude B, Uddin MJ. The economic burden of diarrhea in children under 5 years in Bangladesh. Int J Infect Dis 2021; 107:37-46. [PMID: 33864914 PMCID: PMC8208894 DOI: 10.1016/j.ijid.2021.04.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Diarrhea is a leading cause of morbidity and mortality among under-five children in Bangladesh. Hospitalization for diarrhea can pose a significant burden on households and health systems. The aim of this study was to estimate the cost of illness due to diarrhea from the healthcare facility, caregiver, and societal perspectives in Bangladesh. METHOD A cross-sectional study with an ingredient-based costing approach was conducted in 48 healthcare facilities in Bangladesh. In total, 899 caregivers of under-five children with diarrhea were interviewed face-to-face between August 2017 and May 2018, followed up over phone after 7-14 days of discharge, to capture all expenses and time costs related to the entire episode of diarrhea. RESULTS The average cost per episode for caregivers was US$62, with $29 direct and $34 indirect costs. From the societal perspective, average cost per episode of diarrhea was $71. In 2018, an estimated $79 million of economic costs were incurred for treating diarrhea in Bangladesh. Using 10% of income as threshold, over 46% of interviewed households faced catastrophic expenditure from diarrheal disease. CONCLUSION The economic costs incurred by caregivers for treating per-episode of diarrhea was around 4% of the annual national gross domestic product per-capita. Investment in vaccination can help to reduce the prevalence of diarrheal diseases and avert this public health burden.
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Affiliation(s)
- Md Zahid Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b).
| | - Gazi Golam Mehdi
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
| | - Gatien De Broucker
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Sayem Ahmed
- Mathematical Modelling Group, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom; Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Md Wazed Ali
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
| | - Jorge Martin Del Campo
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Dagna Constenla
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; GlaxoSmithKline Plc., Panama City, Panama
| | - Bryan Patenaude
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Md Jasim Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
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Ogamba CF, Akinsete AM, Mbaso HS, Adesina OA. Health insurance and the financial implications of sickle cell disease among parents of affected children attending a tertiary facility in Lagos, south-west Nigeria. Pan Afr Med J 2021; 36:227. [PMID: 33708318 PMCID: PMC7908317 DOI: 10.11604/pamj.2020.36.227.24636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/11/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction there is a paucity of data on the financial implications of sickle cell disease on households of affected children and their use of health insurance in Nigeria. This study assessed the awareness of health insurance, patterns of health service utilization and financial implications of sickle cell disease among children seeking care at a tertiary facility in Nigeria. Methods a structured questionnaire was administered to parents of 314 children with sickle cell disease attending the pediatric hematology unit of the Lagos University Teaching Hospital between May and December 2019. Results mean age of the children was 91.5 ± 43.1 months. M: F was 1.17: 1. 45.5% of households earned above NGN 150,000 (USD 417) monthly. 71.3% of the parents had heard of health insurance but only 20.7% were enrolled in a health insurance scheme. Awareness of health insurance was significantly associated with social class (p=0.000) and monthly household income (p=0.000). 60.8% of the parents preferred pre-facility treatment. Social class (p=0.01) and monthly household income (p=0.001) were significantly associated with home treatment. Time on admission ranged from 2-18 days with an average of 4.31 days. Average cost of hospitalization was USD 148 ± USD 14.2 and total cost of care incurred was USD 20,787. Neither age of child (p=0.857), estimated household income (p=0.863) nor social class (p=0.397) was associated with cost of care. Conclusion a high cost of care was observed in our study population underscoring the need for increased awareness and access to health insurance for households of children with sickle cell disease.
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Affiliation(s)
| | - Adeseye Michael Akinsete
- Department of Pediatrics, Faculty of Clinical Sciences, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
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Leone M, Ciccacci F, Orlando S, Petrolati S, Guidotti G, Majid NA, Tolno VT, Sagno J, Thole D, Corsi FM, Bartolo M, Marazzi MC. Pandemics and Burden of Stroke and Epilepsy in Sub-Saharan Africa: Experience from a Longstanding Health Programme. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052766. [PMID: 33803352 PMCID: PMC7967260 DOI: 10.3390/ijerph18052766] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/20/2022]
Abstract
Eighty percent of people with stroke live in low- to middle-income nations, particularly in sub-Saharan Africa (SSA) where stroke has increased by more than 100% in the last decades. More than one-third of all epilepsy−related deaths occur in SSA. HIV infection is a risk factor for neurological disorders, including stroke and epilepsy. The vast majority of the 38 million people living with HIV/AIDS are in SSA, and the burden of neurological disorders in SSA parallels that of HIV/AIDS. Local healthcare systems are weak. Many standalone HIV health centres have become a platform with combined treatment for both HIV and noncommunicable diseases (NCDs), as advised by the United Nations. The COVID-19 pandemic is overwhelming the fragile health systems in SSA, and it is feared it will provoke an upsurge of excess deaths due to the disruption of care for chronic diseases such as HIV, TB, hypertension, diabetes, and cerebrovascular disorders. Disease Relief through Excellent and Advanced Means (DREAM) is a health programme active since 2002 to prevent and treat HIV/AIDS and related disorders in 10 SSA countries. DREAM is scaling up management of NCDs, including neurologic disorders such as stroke and epilepsy. We described challenges and solutions to address disruption and excess deaths from these diseases during the ongoing COVID-19 pandemic.
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Affiliation(s)
- Massimo Leone
- The Foundation of the Carlo Besta IRCCS Neurologic Institute, 20133 Milan, Italy
- Correspondence: ; Tel.: +39-02-2394-2304; Fax: +39-02-2394-4057
| | - Fausto Ciccacci
- UniCamillus Saint Camillus International, University of Health Sciences, 00100 Rome, Italy;
| | | | - Sandro Petrolati
- San Camillo Hospital Department of Cardioscience, 00100 Rome, Italy;
| | - Giovanni Guidotti
- Azienda Sanitaria Locale (ASL) Roma 1 Regione Lazio, 00100 Rome, Italy;
| | | | - Victor Tamba Tolno
- Community of S. Egidio DREAM Program, Blantyre 312224, Malawi; (V.T.T.); (J.S.)
| | - JeanBaptiste Sagno
- Community of S. Egidio DREAM Program, Blantyre 312224, Malawi; (V.T.T.); (J.S.)
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Liu M, Luo Z, Zhou D, Ji L, Zhang H, Ghose B, Tang S, Wang R, Feng D. Determinants of health insurance ownership in Jordan: a cross-sectional study of population and family health survey 2017-2018. BMJ Open 2021; 11:e038945. [PMID: 33664063 PMCID: PMC7934725 DOI: 10.1136/bmjopen-2020-038945] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES With about one-third of the population living below the poverty line, Jordan faces major healthcare, social and national development issues. Low insurance coverage among the poor and high out-of-pocket expenditure worsens the financial insecurity especially for the marginalised population. The Government of Jordan aims to achieve universal coverage of health insurance-a bold plan that requires research evidence for successful implementation. In this study, we aimed to assess the proportion of the population covered by any health insurance, and the determinants owing a health insurance. DESIGN A population-based prospective cohort study. SETTING Jordan. METHODS Data for this study were derived from the Jordan Population and Family Health Survey, which was implemented by the Department of Statistics from early October 2017 to January 2018. Sample characteristics were described as percentages with 95% CIs. Binary logistic regression models were used to estimate OR of health insurance ownership. Parsimonious model was employed to assess the sex and geographical differences. RESULTS Data revealed that in 2017-2018, 73.13% of the 12 992 men and women had health insurance. There was no indication of age of sex difference in health insurance ownership; however, marital status and socioeconomic factors such as wealth and education as well as internet access and geographical location appeared to be the important predictors of non-use of health insurance. The associations differed by sex and urbanicity for certain variables. Addressing these inequities may help achieve universal coverage in health insurance ownership in the population. CONCLUSIONS More than one-quarter of the population in Jordan were not insured. Efforts to decrease disparities in insurance coverage should focus on minimising socioeconomic and geographical disparities to promote equity in terms of healthcare services.
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Affiliation(s)
- Meilian Liu
- School of Business, Guilin University of Electronic Technology, Guilin, China
| | - Zhaoxin Luo
- School of Business, Guilin University of Electronic Technology, Guilin, China
| | - Donghua Zhou
- School of Physical Education, Research Center of Sports and Health, Wuhan Business University, Wuhan, China
| | - Lu Ji
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huilin Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bishwajit Ghose
- Social Sciences and Humanities Research Council of Canada, University of Ottawa, Ottawa, Ontario, Canada
| | - Shangfeng Tang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruoxi Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Da Feng
- School of Pharmacy, Huazhong University of Science and Technology, Wuhan, China
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Ssewanyana S, Kasirye I. Estimating Catastrophic Health Expenditures from Household Surveys: Evidence from Living Standard Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) from Sub-Saharan Africa. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:781-788. [PMID: 32909224 PMCID: PMC7481041 DOI: 10.1007/s40258-020-00609-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Out of pocket (OOP) payments for healthcare remain a significant health financing challenge in sub-Saharan Africa (SSA). Understanding the drivers and impacts of this financial health burden is both an economic and a public health priority. OBJECTIVE This study examines how the burden of OOP health expenditures varies with different thresholds for financial catastrophe. METHODS The analysis is based on Livings Standards Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) for five SSA countries-Ethiopia, Malawi, Nigeria, Tanzania, and Uganda. We estimate the degree by which OOP payments as share of total household non-food expenditures exceed either the 15 or 25% threshold. RESULTS For the countries considered, the severity of OOP payments is substantial-the average positive overshoot (beyond the 25% threshold) is above 10%, except for Nigeria. This reflects a higher percentage of OOP in total household health expenditures-compared to taxes and contributions-especially among the poor in these specific countries. Regarding sensitivity of distribution of catastrophic health expenditures, we find that households with low non-food expenditures are more likely to incur catastrophic payments with the exception for Uganda where catastrophic payments increase with the increase of non-food household expenditures. CONCLUSION The burden of catastrophic health expenditures remains large. In order to reduce this burden, public health expenditures need to be expanded as an alternative. This calls for renewed attention to expand public revenues as the most sustainable methods of financing health expenditures in Africa.
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Affiliation(s)
- Sarah Ssewanyana
- Economic Policy Research Centre (EPRC), Makerere University, Kampala, Uganda
| | - Ibrahim Kasirye
- Economic Policy Research Centre (EPRC), Makerere University, Kampala, Uganda
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Mathonnat J, Audibert M, Belem S. Analyzing the Financial Sustainability of User Fee Removal Policies: A Rapid First Assessment Methodology with a Practical Application for Burkina Faso. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:767-780. [PMID: 31432456 PMCID: PMC7716817 DOI: 10.1007/s40258-019-00506-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The purpose of this paper is to briefly present a methodological framework that does not require cumbersome investigations for a first assessment of the financial sustainability of policies aiming to remove or reduce healthcare user fees (the so-called free healthcare policy [FHCP]). This paper is organized in two main sections. The first analyzes the various possibilities available to finance an FHCP. Using several scenarios, it includes a special focus devoted to the calculus of what to consider when assessing the sustainability of expanding fiscal space for financing the FHCP. The second section relies on the current FHCP being implemented in Burkina Faso to illustrate a selection of specific issues raised in the methodological framework. The results suggest that sustainable FHCP financing is not outside the range of the government but does represent a significant challenge, as it will require, both currently and in the future, complex and delicate budget trade-offs at the highest governmental levels, regardless of other policy options to be considered.
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Affiliation(s)
- Jacky Mathonnat
- University Clermont Auvergne and FERDI (Fondation pour les Etudes et Recherches sur le Développement International), 63 Bd François Mitterrand, 63000, Clermont-Ferrand, France.
| | - Martine Audibert
- University Clermont Auvergne, CERDI (Centre d'Etudes et de Recherches sur le Développement International), 26, Avenue Léon Blum, 63000, Clermont-Ferrand, France
| | - Salam Belem
- Sahel Demographic Dividend (SWEDD), Health Development Support Program, Ministry of Health, Ouagadougou, Burkina Faso
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Beaugé Y, Ridde V, Bonnet E, Souleymane S, Kuunibe N, De Allegri M. Factors related to excessive out-of-pocket expenditures among the ultra-poor after discontinuity of PBF: a cross-sectional study in Burkina Faso. HEALTH ECONOMICS REVIEW 2020; 10:36. [PMID: 33188618 PMCID: PMC7666767 DOI: 10.1186/s13561-020-00293-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/04/2020] [Indexed: 06/01/2023]
Abstract
BACKGROUND Measuring progress towards financial risk protection for the poorest is essential within the framework of Universal Health Coverage. The study assessed the level of out-of-pocket expenditure and factors associated with excessive out-of-pocket expenditure among the ultra-poor who had been targeted and exempted within the context of the performance-based financing intervention in Burkina Faso. Ultra-poor were selected based on a community-based approach and provided with an exemption card allowing them to access healthcare services free of charge. METHODS We performed a descriptive analysis of the level of out-of-pocket expenditure on formal healthcare services using data from a cross-sectional study conducted in Diébougou district. Multivariate logistic regression was performed to investigate the factors related to excessive out-of-pocket expenditure among the ultra-poor. The analysis was restricted to individuals who reported formal health service utilisation for an illness-episode within the last six months. Excessive spending was defined as having expenditure greater than or equal to two times the median out-of-pocket expenditure. RESULTS Exemption card ownership was reported by 83.64% of the respondents. With an average of FCFA 23051.62 (USD 39.18), the ultra-poor had to supplement a significant amount of out-of-pocket expenditure to receive formal healthcare services at public health facilities which were supposed to be free. The probability of incurring excessive out-of-pocket expenditure was negatively associated with being female (β = - 2.072, p = 0.00, ME = - 0.324; p = 0.000) and having an exemption card (β = - 1.787, p = 0.025; ME = - 0.279, p = 0.014). CONCLUSIONS User fee exemptions are associated with reduced out-of-pocket expenditure for the ultra-poor. Our results demonstrate the importance of free care and better implementation of existing exemption policies. The ultra-poor's elevated risk due to multi-morbidities and severity of illness need to be considered when allocating resources to better address existing inequalities and improve financial risk protection.
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Affiliation(s)
- Yvonne Beaugé
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
| | - Valéry Ridde
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université de Paris), ERL INSERM SAGESUD, Paris, France
| | - Emmanuel Bonnet
- French Institute for Research on Sustainable Development (IRD), Unité Mixte Internationale (UMI) Résiliences, Paris, France
| | - Sidibé Souleymane
- UFR SDS EDS Université Ouaga 1 Professor JKZ, IRD (French Institute for Research on sustainable Development), AGIR - Global Alliance for Resilience, Paris, France
| | - Naasegnibe Kuunibe
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
- Department of Economics and Entrepreneurship Development Studies, Faculty of Integrated Development Studies, University for Development Studies, Wa, Upper West Region, Ghana
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
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de Broucker G, Ahmed S, Hasan MZ, Mehdi GG, Martin Del Campo J, Ali MW, Uddin MJ, Constenla D, Patenaude B. The economic burden of measles in children under five in Bangladesh. BMC Health Serv Res 2020; 20:1026. [PMID: 33172442 PMCID: PMC7653835 DOI: 10.1186/s12913-020-05880-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/30/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This study estimated the economic cost of treating measles in children under-5 in Bangladesh from the caregiver, government, and societal perspectives. METHOD We conducted an incidence-based study using an ingredient-based approach. We surveyed the administrative staff and the healthcare professionals at the facilities, recording their estimates supported by administrative data from the healthcare perspective. We conducted 100 face-to-face caregiver interviews at discharge and phone interviews 7 to 14 days post-discharge to capture all expenses, including time costs related to measles. All costs are in 2018 USD ($). RESULTS From a societal perspective, a hospitalized and ambulatory case of measles cost $159 and $18, respectively. On average, the government spent $22 per hospitalized case of measles. At the same time, caregivers incurred $131 and $182 in economic costs, including $48 and $83 in out-of-pocket expenses in public and private not-for-profit facilities, respectively. Seventy-eight percent of the poorest caregivers faced catastrophic health expenditures compared to 21% of the richest. In 2018, 2263 cases of measles were confirmed, totaling $348,073 in economic costs to Bangladeshi society, with $121,842 in out-of-pocket payments for households. CONCLUSION The resurgence of measles outbreaks is a substantial cost for society, requiring significant short-term public expenditures, putting households into a precarious financial situation. Improving vaccination coverage in areas where it is deficient (Sylhet division in our study) would likely alleviate most of this burden.
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Affiliation(s)
- Gatien de Broucker
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, #530, Baltimore, MD, 21231, USA.
| | - Sayem Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Liverpool School of Tropical Disease (LSTM), Liverpool, UK
| | - Md Zahid Hasan
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Gazi Golam Mehdi
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jorge Martin Del Campo
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, #530, Baltimore, MD, 21231, USA
| | - Md Wazed Ali
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Jasim Uddin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Dagna Constenla
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, #530, Baltimore, MD, 21231, USA
- GlaxoSmithKline Plc, Panama City, Panama
| | - Bryan Patenaude
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, #530, Baltimore, MD, 21231, USA
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Kwesiga B, Aliti T, Nabukhonzo P, Najuko S, Byawaka P, Hsu J, Ataguba JE, Kabaniha G. What has been the progress in addressing financial risk in Uganda? Analysis of catastrophe and impoverishment due to health payments. BMC Health Serv Res 2020; 20:741. [PMID: 32787844 PMCID: PMC7425531 DOI: 10.1186/s12913-020-05500-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 07/02/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Monitoring progress towards Universal Health Coverage (UHC) requires an assessment of progress in coverage of health services and protection of households from the impact of direct out-of-pocket payments (i.e. financial risk protection). Although Uganda has expressed aspirations for attaining UHC, out-of-pocket payments remain a major contributor to total health expenditure. The aim of this study is to monitor progress in financial risk protection in Uganda. METHODS This study uses data from the Uganda National Household Surveys for 2005/06, 2009/10, 2012/13 and 2016/17. We measure financial risk protection using catastrophic health care payments and impoverishment indicators. Health care payments are catastrophic if they exceed a set threshold (i.e. 10 and 25%) of the total household consumption expenditure. Health payments are impoverishing if they push the household below the poverty line (the US$1.90/day and Uganda's national poverty lines). A logistic regression model is used to assess the factors associated with household financial risk. RESULTS The results show that while progress has been made in reducing financial risk, this progress remains minimal, and there is still a risk of a reversal of this trend. We find that although catastrophic health payments at the 10% threshold decreased from 22.4% in 2005/06 to 13.8% in 2012/13, it increased to 14.2% in 2016/17. The percentage of Ugandans pushed below the national poverty line (US$1.90/day) has decreased from 5.2% in 2005/06 to 2.7% in 2016/17. The distribution of both catastrophic health payments and impoverishment varies across socio-economic status, location and residence. In addition, certain household characteristics (poverty, having a child below 5 years and an adult above 60 years) are more associated with the lack of financial risk protection. CONCLUSION There is need for targeted interventions to reduce OOP, especially among those affected so as to increase financial risk protection. In the short-term, it is important to ensure that public health services are funded adequately to enable effective coverage with quality health care. In the medium-term, increased reliance on mandatory prepayment will reduce the burden of OOP health spending further.
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Affiliation(s)
- Brendan Kwesiga
- World Health Organization, Health Systems Cluster, Nairobi, Kenya
| | - Tom Aliti
- Ministry of Health, Planning Department, Kampala, Uganda
| | | | - Susan Najuko
- Ministry of Health, Planning Department, Kampala, Uganda
| | | | - Justine Hsu
- World Health Organization, Economic Analysis Cluster, Geneva, Switzerland
| | - John E. Ataguba
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Grace Kabaniha
- World Health Organization, Health Systems Cluster India Country Office, New Delhi, India
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Catastrophic health expenditures arising from out-of-pocket payments: Evidence from South African income and expenditure surveys. PLoS One 2020; 15:e0237217. [PMID: 32780758 PMCID: PMC7418962 DOI: 10.1371/journal.pone.0237217] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/22/2020] [Indexed: 01/07/2023] Open
Abstract
This study examines catastrophic health expenditures and the potential for such payments to impoverish South African households. The analysis applies three different catastrophic expenditure measurements, and we apply them across four South African Income and Expenditure Surveys. Since households have limited resources, they are also limited in their capacity to purchase health care. Thus, if a household devotes a large share of that capacity to health care, it may not be able to cover other necessary expenses, which could be catastrophic. The measurements differ in their definition of household capacity. Despite the differences in measurements, and, therefore, results, we find limited incidence of health care expenditure catastrophe, although larger shares of capacity are being devoted to health care in more recent years. In line with the finding that catastrophe is rare, we find that very few households are subsequently impoverished, because of health care costs.
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Nakovics MI, Brenner S, Bongololo G, Chinkhumba J, Kalmus O, Leppert G, De Allegri M. Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi. HEALTH ECONOMICS REVIEW 2020; 10:14. [PMID: 32462272 PMCID: PMC7254643 DOI: 10.1186/s13561-020-00271-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/08/2020] [Indexed: 06/01/2023]
Abstract
BACKGROUND Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services. METHODS Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place. RESULTS Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p2 = 0.018; p3 = 0.001; p4 = 0.002), and urban residency (p = 0.001). CONCLUSION Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.
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Affiliation(s)
- Meike Irene Nakovics
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Grace Bongololo
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Jobiba Chinkhumba
- University of Malawi College of Medicine, Blantyre, Southern Region Malawi
| | - Olivier Kalmus
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Gerald Leppert
- German Institute for Development Evaluation (DEval), Bonn, Germany
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
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Doshmangir L, Yousefi M, Hasanpoor E, Eshtiagh B, Haghparast-Bidgoli H. Determinants of catastrophic health expenditures in Iran: a systematic review and meta-analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:17. [PMID: 32467673 PMCID: PMC7229629 DOI: 10.1186/s12962-020-00212-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/06/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Catastrophic health expenditures (CHE) are of concern to policy makers and can prevent individuals accessing effective health care services. The exposure of households to CHE is one of the indices used to evaluate and address the level of financial risk protection in health systems, which is a key priority in the global health policy agenda and an indicator of progress toward the UN Sustainable Development Goal for Universal Health Coverage. This study aims to assess the CHE at population and disease levels and its influencing factors in Iran. METHODS This study is a systematic review and meta-analysis. The following keywords and their Persian equivalents were used for the review: Catastrophic Health Expenditures; Health Equity; Health System Equity; Financial Contribution; Health Expenditures; Financial Protection; Financial Catastrophe; and Health Financing Equity. These keywords were searched with no time limit until October 2019 in PubMed, Web of Science, Scopus, ProQuest, ScienceDirect, Embase, and the national databases of Iran. Studies that met a set of inclusion criteria formed part of the meta-analysis and results were analyzed using a random-effects model. RESULTS The review identified 53 relevant studies, of which 40 are conducted at the population level and 13 are disease specific. At the population level, the rate of CHE is 4.7% (95% CI 4.1% to 5.3%, n = 52). Across diseases, the percentage of CHE is 25.3% (95% CI 11.7% to 46.5%, n = 13), among cancer patients, while people undergoing dialysis face the highest percentage of CHE (54.5%). The most important factors influencing the rate of CHE in these studies are health insurance status, having a household member aged 60-65 years or older, gender of the head of household, and the use of inpatient and outpatient services. CONCLUSION The results suggest that catastrophic health spending in Iran has increased from 2001 to 2015 and has reached its highest levels in the last 5 years. It is therefore imperative to review and develop fair health financing policies to protect people against financial hardship. This review and meta-analysis provides evidence to help inform effective health financing strategies and policies to prioritise high-burden disease groups and address the determinants of CHE.
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Affiliation(s)
- Leila Doshmangir
- Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran
- Social Determinants of Health Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahmood Yousefi
- Department of Health Economics, School of Health Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Edris Hasanpoor
- Research Center for Evidence-Based Health Management, Maragheh University of Medical Sciences, Maragheh, Iran
| | - Behzad Eshtiagh
- Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
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Acceptance for Social Health Insurance among Health Professionals in Government Hospitals, Mekelle City, North Ethiopia. ADVANCES IN PUBLIC HEALTH 2020. [DOI: 10.1155/2020/6458425] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. Ethiopia is one of the countries with high out-of-pocket payments leading to catastrophic health expenditure. The government of Ethiopia introduced social health insurance (SHI) scheme with the overall objective of achieving universal health care access. Studying health professionals’ acceptance to pay for social health insurance is crucial for the successful implementation of the scheme. Therefore, this study aimed to assess the acceptance of social health insurance and its associated factors among health professionals in government hospitals, Mekelle city, North Ethiopia. Methods. An institution-based cross-sectional study design was used. The study participants were selected using systematic random sampling. Data were collected using a structured interviewer-administered questionnaire and analyzed using SPSS version 20. Bivariable and multivariable logistic regression models at a 5% level of significance, and odds ratios with 95% CI level were used to determine the association between the health professionals’ acceptance of health insurance and explanatory variables. Results. The study revealed that 62.5% of the respondents were willing to participate in the SHI scheme in which 74.9% were willing to pay 3% or more of their monthly salary. Health professionals’ acceptance for SHI significantly associated with monthly salary (AOR = 9.49; 95% CI: 2.51, 35.86), awareness about SHI (AOR = 3.89; 95% CI: 1.05, 14.28), history of difficulty in covering medical bills (AOR = 6.2; 95% CI: 2.42, 15.87), attitudes towards social health insurance (AOR = 7.57; 95% CI: 3.14, 18.21), and perceived quality of health care services if SHI implemented (AOR = 2.89; 95% CI: 1.18, 7.07). Conclusion. The study indicated that there were still a high proportion of health professionals who were not willing to pay for SHI. Therefore, strengthening awareness creation, creating awareness about SHI, promoting the scheme using the different channels of communication to bring about favorable attitude, and providing health care services with required standard quality could help to increase the acceptance of SHI by health professionals.
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Ajayi AI, Akpan W. Maternal health care services utilisation in the context of 'Abiye' (safe motherhood) programme in Ondo State, Nigeria. BMC Public Health 2020; 20:362. [PMID: 32192429 PMCID: PMC7082975 DOI: 10.1186/s12889-020-08512-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Nigeria Demographic and Health Survey (NDHS) of 2008 show that Ondo State had the worst maternal outcomes in the South Western region of Nigeria. To address this problem, the "Abiye" (safe motherhood) programme-which included community engagement, health system strengthening and user fee removal- was implemented by the state government. We assessed the use of maternal health care services and its determinants at 5 years after the implementation of this programme using a population-based survey. We also compared the results of our survey to the NDHS 2013 to assess improvement in maternal health care services utilisation. METHODS We conducted a population-based survey in 2016 among representative sample of 409 women who had given birth between 2011 and 2015, which were selected using cluster random sampling. We compared the findings of this 2016 survey to the 2013 NDHS, which contains maternal health care services utilisation information of a total of 434 women who gave birth between 2009 and 2013 to assess progress in the use of maternal health care services. We used descriptive and inferential statistics for our data analysis. RESULTS In the 2013 NDHS survey, about 80% of women received antenatal care compared to 98% in the 2016 survey. Our survey shows that the majority of births (85.6%) took place in health facilities compared to only 56.5% in NDHS 2013 survey, which represents a 29.1 percentage points increase. In both surveys, women with primary level of education or less had lower odds of delivering their babies in health facilities. However, while the 2013 NDHS survey shows that women who resided in urban areas were twice more likely to deliver their babies in health facilities compared to those living in rural areas, the 2016 survey shows that urban residence was no longer significantly associated with a higher odds of facility-based child delivery. CONCLUSION Maternal health services utilisation has improved considerably following the implementation of the "Abiye" initiative. The findings of this study suggest that with community engagement, health system strengthening and user fee removal for the most vulnerable, universal access to and utilisation of maternal health services is possible.
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Affiliation(s)
- Anthony Idowu Ajayi
- Population Dynamics and Sexual and Reproductive Health and Rights Unit, African Population and Health Research Center, Manga Close, Off Kirawa Road, Kitisuru, Nairobi, 00100, Kenya.
| | - Wilson Akpan
- Research and Innovation, Walter Sisulu University, Nelson Mandela Drive, Mthatha, South Africa
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Ajayi AI. "I am alive; my baby is alive": Understanding reasons for satisfaction and dissatisfaction with maternal health care services in the context of user fee removal policy in Nigeria. PLoS One 2019; 14:e0227010. [PMID: 31869385 PMCID: PMC6927641 DOI: 10.1371/journal.pone.0227010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/09/2019] [Indexed: 11/25/2022] Open
Abstract
Background The main policy thrust in many sub-Saharan Africa countries’ aim at addressing maternal mortality is the elimination of the user fee for maternal healthcare services. While several studies have documented the effect of the user fee removal policy on the use of maternal health care services, the experiences of women seeking care in facilities offering free obstetrics services, their level of satisfaction and reasons for satisfaction or dissatisfaction are poorly understood. Methods This study adopted a mixed study design involving a population survey of 1227 women of reproductive age who gave birth in the last five years preceding the study (2011–2015), 68 in-depth interviews, and six focus group discussions. Simple descriptive statistics were performed on 407 women who benefitted from the user fee removal policy, while the qualitative data were analysed using thematic analysis. Results The overall level of satisfaction with care received was remarkably high (97.1%), with birth outcomes being the central reason for their satisfaction. Participants were also satisfied with both the process aspect of care (which includes health workers’ attitude and privacy) and the structural dimension of care (such as, the cleanliness of health care facilities and availability of and access to medicine). From the qualitative analysis, prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space were the main reasons why a few women were dissatisfied with care under free maternal health care. Conclusion The findings establish a high level of beneficiaries’ satisfaction with care under free maternal health policy in Nigeria, raising the need for sustaining the policy in expanding access to maternal health services for the poor. Nevertheless, issues relating to prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space require attention from policymakers.
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Affiliation(s)
- Anthony Idowu Ajayi
- Population Dynamics and Reproductive Health and Right Unit, African Population and Health Research Center, APHRC Campus, Nairobi, Kenya
- * E-mail:
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Rahimi A, Kassam R, Dang Z, Sekiwunga R. Challenges with accessing health care for young children presumed to have malaria in the rural district of Butaleja, Uganda: a qualitative study. Pharm Pract (Granada) 2019; 17:1622. [PMID: 31897260 PMCID: PMC6935545 DOI: 10.18549/pharmpract.2019.4.1622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/27/2019] [Indexed: 11/17/2022] Open
Abstract
Objective: A qualitative study was conducted to gain insight into challenges reported by
Butaleja households during a previous household survey. Specifically, this
paper discusses heads of households’ and caregivers’
perceptions of challenges they face when seeking care for their very young
children with fever presumed to be malaria. Methods: Eleven focus groups (FGs) were carried out with household members (five with
heads of households and six with household caregivers) residing in five
sub-counties located across the district. Purposive sampling was used to
ensure the sample represented the religious diversity and geographical
distance from the peri-urban center of the district. Each FG consisted of
five to six participants. The FGs were conducted at a community centre by
two pairs of researchers residing in the district and who were fluent in
both English and the local dialect of Lunyole. The discussions were
recorded, translated, and transcribed. Transcripts were reviewed and coded
with the assistance of QDA Miner (version 4.0) qualitative data management
software, and analyzed using thematic content analysis. Results: The FG discussions identified four major areas of challenges when managing
acute febrile illness in their child under the age of five with presumed
malaria (1) difficulties with getting to public health facilities due to
long geographical distances and lack of affordable transportation; (2) poor
service once at a public health facility, including denial of care, delay in
treatment, and negative experiences with the staff; (3) difficulties with
managing the child’s illness at home, including challenges with
keeping home-stock medicines and administering medicines as prescribed; and
(4) constrained to use private outlets despite their shortcomings. Conclusions: Future interventions may need to look beyond the public health system to
improve case management of childhood malaria at the community level in rural
districts such as Butaleja. Given the difficulties with accessing quality
private health outlets, there is a need to partner with the private sector
to explore feasible models of community-based health insurance programs and
expand the role of informal private providers.
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Affiliation(s)
- Asa Rahimi
- BSc (Hons). Faculty of Medicine, University of British Columbia. Vancouver, BC (Canada).
| | - Rosemin Kassam
- BSc Pharm, ACPR, PharmD, PhD. Professor. School of Population and Public Health, Faculty of Medicine, University of British Columbia. Vancouver, BC (Canada).
| | - Zhong Dang
- BSc MBIM. Research Assistant. School of Population and Public Health, Faculty of Medicine, University of British Columbia. Vancouver, BC (Canada).
| | - Richard Sekiwunga
- MSc PRH. Scientist. Child Health and Development Centre, School of Medicine, Makerere University, Kampala (Uganda).
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Ebaidalla EM, Ali MEM. Determinants and impact of household's out-of-pocket healthcare expenditure in Sudan: evidence from urban and rural population. ACTA ACUST UNITED AC 2019. [DOI: 10.1080/17938120.2019.1668163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rezaei S, Woldemichael A, Hajizadeh M, Kazemi Karyani A. Catastrophic healthcare expenditures among Iranian households: a systematic review and meta-analysis. INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTH CARE 2019. [DOI: 10.1108/ijhrh-02-2018-0017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Protecting households against financial risks of healthcare services is one of the main functions of health systems. The purpose of this paper is to provide a pooled estimate of the prevalence of catastrophic healthcare expenditures (CHE) among households in Iran.
Design/methodology/approach
Both international (PubMed, Scopus and Clarivate Analytics (previously known as the Institute for Scientific Information)) and Iranian (Scientific Information Database, Iranmedex and Magiran) scientific databases were searched for published studies on CHE among Iranian households. The following keywords in Persian and English language were used as keywords for the search: “catastrophic healthcare costs,” “catastrophic health costs,” “impoverishment due to health costs,” “fair financial contribution,” “prevalence,” “frequency” and “Iran” with and without “health system”. The I2-test and χ2-based Q-test suggested heterogeneity in the reported prevalence among the qualified studies; thus, a random-effects model was used to estimate the overall prevalence of CHE among households in Iran.
Findings
A total of 24 studies with a cumulative sample of 301,097 households were included in the study. The estimated pooled prevalence of CHE among households was 7 percent (95 percent confidence interval: 6–8 percent). Meta-regression analysis indicated that the prevalence of CHE was inversely related to the sample size (p<0.05). The results did not suggest a significant association between the prevalence of CHE and the year of data collection.
Originality/value
The findings revealed that the prevalence of CHE among Iranian households is significantly higher than 1 percent, which is the goal set out in Iran’s fourth five-year development plan. This warrants further policy interventions to protect households from incurring CHE in Iran.
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Nundoochan A, Thorabally Y, Monohur S, Hsu J. Impact of out of pocket payments on financial risk protection indicators in a setting with no user fees: the case of Mauritius. Int J Equity Health 2019; 18:63. [PMID: 31053077 PMCID: PMC6500054 DOI: 10.1186/s12939-019-0959-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/16/2019] [Indexed: 12/20/2022] Open
Abstract
Background Mauritius embraces principles of a welfare state with free health care at point of use in any public facilities. However, the health financing landscape changed in 2007 when Private Health Expenditure (PvtHE) surpassed General Government Health Expenditure. PvtHE is predominately out of pocket (OOP) with only 3.4% related to premiums for private insurance. In 2014, Household OOP Expenditure on health accounted for 52.8% of total health expenditure. OOP is known to be regressive and to impact negatively on households’ living standards. Objectives This paper aims to examine trends in OOP in Mauritius, to assess its impacts through an analysis of key indicators of financial protection, namely catastrophic health expenditure (CHE) and impoverishment due to OOP health expenditure. It also aims to predict core determinants of CHEs. Methods Household Budget Surveys (HBS) of 2001/2002, 2006/2007 and 2012 were the primary source data. CHE and impoverishment were used to assess financial hardships resulting from OOP health payments. The incidence of CHE was estimated at three threshold levels (10,25 and 40%), using the budget share and the capacity to pay approaches. Impoverishment due to OOP was measured by changes in the incidence of poverty and intensity of poverty using the US$ 3.1 international poverty line. Logistic regression analysis was used to identify determinants of CHE. Findings Household CHE increased from 5.78% in 2001/02 to 8.85% in 2012 and 0.61% in 2001/02 to 1.25% in 2012, for 10 and 40% thresholds, respectively. The incidence of CHE was significantly higher in urban areas compared to rural areas. The highest levels of CHEs were among households’ heads, who are retired rising from 1.62% in 2001/02 to 3.71% in 2012, followed by households’ head who are widowed from 2.29% in 2001/02 to 2.63% in 2012 and homemakers from 2.12% in 2001/02 to 2.57% in 2012 at the 40% threshold. The share of households pushed below the poverty line due to OOP dropped from 0.4% in 2001/02 to 0.2% in 2006/07 before rising to 0.34% in 2012. In 2012, poverty gap occurred only among households under poorest quintile 1 (0.24%) and quintile 2 (0.03%). Overall poverty gap dropped from 0.08% in 2001/02 to 0.05% in 2012. Logistic regression analysis revealed that the odds ratio of facing CHE were significant only among households with heads being retired and with a presence of an elderly member in the household. Conclusion Despite the rise in incidence of CHE between 2001 and 2012 the impact of OOP on the level of impoverishment and poverty gap has not been significant.
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Affiliation(s)
- Ajoy Nundoochan
- World Health Organization Country Office, Port Louis, Mauritius.
| | | | | | - Justine Hsu
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
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Liu L, Zhang X, Zhao L, Li N. Empirical Analysis of the Status and Influencing Factors of Catastrophic Health Expenditure of Migrant Workers in Western China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050738. [PMID: 30823652 PMCID: PMC6427712 DOI: 10.3390/ijerph16050738] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/19/2019] [Accepted: 02/22/2019] [Indexed: 12/05/2022]
Abstract
Objective: To understand the current situation and influencing factors of catastrophic health expenditure (CHE) of migrant workers in Western China. Method: Sample data were obtained by cluster random sampling. Data were entered and sorted using Epidata 3.1 and SPSS 21.0. The statistical analysis involved a descriptive analysis, chi-square tests, multivariate unconditional logistic regression, and multiple correspondence analysis (MCA). Results: A total of 1271 households were surveyed, and the incidence of CHE was 12.5% (159/1271). The multivariate logistic regression showed that households with elderly people over 65 years old (0R = 2.05, 95% CI = 1.42–2.97), children under five years old (0R = 2.61, 95% CI = 1.53–4.48), at least one person with no basic medical insurance (0R = 2.96, 95% CI = 2.08–4.23), chronically ill patients (0R = 1.85, 95% CI = 1.23–2.77), and hospitalized patients (0R = 3.61, 95% CI = 2.31–5.62) contributed to the risk of CHE. Compared to migrant workers in the >30,000 Yuan household per capita annual income group, the 10,001–20,000 Yuan income group (0R = 2.35, 95% CI = 1.44–3.82) and ≤10,000 Yuan income group (0R = 3.72, 95% CI = 2.09–6.62) had a higher risk of CHE occurrence. Compared to migrant workers in the university and above head-of-household education group, those in the primary level or below education group (0R = 5.90, 95% CI = 3.02–11.5) had a higher risk of CHE occurrence. MCA revealed a strong interrelationship between the following risk factors and CHE: household per capita annual income ≤10,000 Yuan, primary school education level or below for the head of the household, and having at least one person in the household with no basic medical insurance. Conclusions: CHE incidence amongst migrant workers in Western China is a serious issue, and policymakers should pay more attention to these migrant workers’ households that are more prone to CHE than others, so as to decrease the incidence of CHE in this group.
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Affiliation(s)
- Li Liu
- West China School of Public Health, Sichuan University, Chengdu 610041, China.
| | - Xuewen Zhang
- School of Public Health, Jining Medical University, Jining 272067, China.
| | - Longchao Zhao
- West China School of Public Health, Sichuan University, Chengdu 610041, China.
| | - Ningxiu Li
- West China School of Public Health, Sichuan University, Chengdu 610041, China.
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Azzani M, Roslani AC, Su TT. Determinants of Household Catastrophic Health Expenditure: A Systematic Review. Malays J Med Sci 2019; 26:15-43. [PMID: 30914891 PMCID: PMC6419871 DOI: 10.21315/mjms2019.26.1.3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/03/2018] [Indexed: 01/07/2023] Open
Abstract
The World Health Organization estimates that annually 150 million people experience severe (catastrophic) financial difficulties as a result of healthcare payments. Therefore, a systematic review was carried out to identify the determinants of household catastrophic health expenditure (CHE) in low-to high-income countries around the world. Both electronic and manual searches were conducted. The main outcome of interest was the determinants of CHE due to healthcare payments. Thirty eight studies met the inclusion criteria for review. The analysis revealed that household economic status, incidence of hospitalisation, presence of an elderly or disabled household member in the family, and presence of a family member with a chronic illness were the common significant factors associated with household CHE. The crucial finding of the current study is that socioeconomic inequality plays an important role in the incidence of CHE all over the world, where low-income households are at high risk of financial hardship from healthcare payments. This suggests that healthcare financing policies should be revised in order to narrow the gap in socioeconomic inequality and social safety nets should be implemented and strengthened for people who have a high need for health care.
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Affiliation(s)
- Meram Azzani
- Community Medicine Department, Faculty of Medicine & Biomedical Sciences, MAHSA University, Saujana Putra Campus, 42610 Jenjarom, Selangor, Malaysia
| | - April Camilla Roslani
- University of Malaya Cancer Research Institute (UMCRI), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Tin Tin Su
- Centre for Population Health (CePH), Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
- South East Asia Community Observatory (SEACO), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500 Bandar Sunway, Selangor, Malaysia
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Soremekun S, Kasteng F, Lingam R, Vassall A, Kertho E, Settumba S, Etou PL, Nanyonjo A, ten Asbroek G, Kallander K, Kirkwood B. Variation in the quality and out-of-pocket cost of treatment for childhood malaria, diarrhoea, and pneumonia: Community and facility based care in rural Uganda. PLoS One 2018; 13:e0200543. [PMID: 30475808 PMCID: PMC6261061 DOI: 10.1371/journal.pone.0200543] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/28/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A key barrier to appropriate treatment for malaria, diarrhoea, and pneumonia (MDP) in children under 5 years of age in low income rural settings is the lack of access to quality health care. The WHO and UNICEF have therefore called for the scale-up of integrated community case management (iCCM) using community health workers (CHWs). The current study assessed access to treatment, out-of-pocket expenditure and the quality of treatment provided in the public and private sectors compared to national guidelines, using data collected in a large representative survey of caregivers of children in 205 villages with iCCM-trained CHWs in mid-Western Uganda. RESULTS The prevalence of suspected malaria, diarrhoea and suspected pneumonia in the preceding two weeks in 6501 children in the study sample were 45%, 11% and 24% respectively. Twenty percent of children were first taken to a CHW, 56% to a health facility, 14% to other providers and no care was sought for 11%. The CHW was more likely to provide appropriate treatment compared to any other provider or to those not seeking care for children with MDP (RR 1.51, 95% CI 1.42-1.61, p<0.001). Seeking care from a CHW had the lowest cost outlay (median $0.00, IQR $0.00-$1.80), whilst seeking care to a private doctor or clinic the highest (median $2.80, IQR $1.20-$6.00). We modelled the expected increase in overall treatment coverage if children currently treated in the private sector or not seeking care were taken to the CHW instead. In this scenario, coverage of appropriate treatment for MDP could increase in total from the current rate of 47% up to 64%. CONCLUSION Scale-up of iCCM-trained CHW programmes is key to the provision of affordable, high quality treatment for sick children, and can thus significantly contribute to closing the gap in coverage of appropriate treatment.
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Affiliation(s)
- Seyi Soremekun
- Department of Population Health, London School of Hygiene and Tropical Medicine, London United Kingdom
| | - Frida Kasteng
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London United Kingdom
- Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Raghu Lingam
- Department of Population Health, London School of Hygiene and Tropical Medicine, London United Kingdom
- Institute of Health and Society, Newcastle University, Newcastle, United Kingdom
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London United Kingdom
| | | | - Stella Settumba
- The Malaria Consortium, Kampala, Uganda
- National Perinatal Epidemiology and Statistics Unit, University of New South Wales, Sidney, Australia
| | - Patrick L. Etou
- Institute of Health and Society, Newcastle University, Newcastle, United Kingdom
| | - Agnes Nanyonjo
- The Malaria Consortium, Kampala, Uganda
- African Population Health Research Centre, Nairobi, Kenya
| | - Guus ten Asbroek
- Department of Population Health, London School of Hygiene and Tropical Medicine, London United Kingdom
- Department of Global Health, Academic Medical Centre, Amsterdam, The Netherlands
| | - Karin Kallander
- Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- The Malaria Consortium, London, United Kingdom
| | - Betty Kirkwood
- Department of Population Health, London School of Hygiene and Tropical Medicine, London United Kingdom
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Haven N, Dobson AE, Yusuf K, Kellermann S, Mutahunga B, Stewart AG, Wilkinson E. Community-Based Health Insurance Increased Health Care Utilization and Reduced Mortality in Children Under-5, Around Bwindi Community Hospital, Uganda Between 2015 and 2017. Front Public Health 2018; 6:281. [PMID: 30356909 PMCID: PMC6190927 DOI: 10.3389/fpubh.2018.00281] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 09/11/2018] [Indexed: 01/25/2023] Open
Abstract
Introduction: Out-of-pocket fees to pay for health care prevent poor people from accessing health care and drives millions into poverty every year. This obstructs progress toward the World Health Organization goal of universal health care. Community-based health insurance (CBHI) improves access to health care primarily by reducing the financial risk. The association of CBHI with reduced under-5 mortality was apparent in some voluntary schemes. This study evaluated the impact of eQuality Health Bwindi CBHI scheme on health care utilization and under-5 mortality in rural south-western Uganda. Methods: This was a retrospective cross-sectional study using routine electronic data on health insurance status, health care utilization, place of birth, and deaths for children aged under-5 in the catchment area of Bwindi Community Hospital, Uganda between January 2015 and June 2017. Data was extracted from four electronic databases and cross matched. To assess the association with health insurance, we measured the difference between those with and without insurance; in terms of being born in a health facility, outpatient attendance, inpatient admissions, length of stay and mortality. Associations were assessed by Chi-Square tests with p-values < 0.05 and 95% confidence intervals. For variables found to be significant at this level, multivariable logistic regression was done to control for possible confounders. Results: Of the 16,464 children aged under-5 evaluated between January 2015 and June 2017, 10% were insured all of the time 19% were insured for part of the period, and 71% were never insured. Ever having had health insurance reduced the risk of death by 36% [aOR; 0.64, p = 0.009]. While children were insured, they visited outpatients ten times more, and were four times more likely to be admitted. If admitted, they had a significantly shorter length of stay. If mother was uninsured, children were less likely to be born in a health facility [adjusted odds ratio (aOR) 2.82, p < 0.001]. Conclusion: This study demonstrated that voluntary CBHI increased health care utilization and reduced mortality for children under-5. But the scheme required appreciable outside subsidy, which limits its wider application and replicability. While CBHIs can contribute to progress toward Universal Health Care they cannot always be afforded.
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Affiliation(s)
- Nahabwe Haven
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Andrew E. Dobson
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Kuule Yusuf
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Scott Kellermann
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Birungi Mutahunga
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Alex G. Stewart
- College of Life and Environmental Science, University of Exeter, Exeter, United Kingdom
| | - Ewan Wilkinson
- Institute of Medicine, University of Chester, Chester, United Kingdom
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Benova L, Dennis ML, Lange IL, Campbell OMR, Waiswa P, Haemmerli M, Fernandez Y, Kerber K, Lawn JE, Santos AC, Matovu F, Macleod D, Goodman C, Penn-Kekana L, Ssengooba F, Lynch CA. Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys. BMC Health Serv Res 2018; 18:758. [PMID: 30286749 PMCID: PMC6172797 DOI: 10.1186/s12913-018-3546-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 09/17/2018] [Indexed: 11/11/2022] Open
Abstract
Background Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011. Methods We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests. Results Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency; < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components. Conclusions The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care (facility delivery). Providers in both sectors require quality improvements. Achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women despite competing priorities for financial and human resources. Electronic supplementary material The online version of this article (10.1186/s12913-018-3546-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lenka Benova
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Mardieh L Dennis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Isabelle L Lange
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Peter Waiswa
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Yolanda Fernandez
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kate Kerber
- Saving Newborn Lives, Save the Children, 899 North Capitol Street, Suite 900, Washington, DC, 20002, USA.,Indigenous & Global Health Research Group, Department of Medicine, University of Alberta, University Terrace, 8303-112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Joy E Lawn
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Andreia Costa Santos
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Fred Matovu
- School of Economics, Makerere University Kampala, Uganda and Policy Analysis & Development Research Institute (PADRI), Kampala, Uganda
| | - David Macleod
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Freddie Ssengooba
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Caroline A Lynch
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Arunda M, Emmelin A, Asamoah BO. Effectiveness of antenatal care services in reducing neonatal mortality in Kenya: analysis of national survey data. Glob Health Action 2018. [PMID: 28621201 PMCID: PMC5496054 DOI: 10.1080/16549716.2017.1328796] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Although global neonatal mortality declined by about 40 percent from 1990 to 2013, it still accounted for about 2.6 million deaths globally and constituted 42 percent of global under-five deaths. Most of these deaths occur in developing countries. Antenatal care (ANC) is a globally recommended strategy used to prevent neonatal deaths. In Kenya, over 90 percent of pregnant women attend at least one ANC visit during pregnancy. However, Kenya is currently among the 10 countries that contribute the most neonatal deaths globally. OBJECTIVE The aim of this study is to examine the effectiveness of ANC services in reducing neonatal mortality in Kenya. METHODS We used binary logistic regression to analyse cross-sectional data from the 2014 Kenya Demographic and Health Survey to investigate the effectiveness of ANC services in reducing neonatal mortality in Kenya. We determined the population attributable neonatal mortality fraction for the lack of selected antenatal interventions. RESULTS The highest odds of neonatal mortality were among neonates whose mothers did not attend any ANC visit (adjusted odds ratio [aOR] 4.0, 95% confidence interval [CI] 1.7-9.1) and whose mothers lacked skilled ANC attendance during pregnancy (aOR 3.0, 95% CI 1.4-6.1). Lack of tetanus injection relative to one tetanus injection was significantly associated with neonatal mortality (aOR 2.5, 95% CI 1.0-6.0). About 38 percent of all neonatal deaths in Kenya were attributable to lack of check-ups for pregnancy complications. CONCLUSIONS Lack of check-ups for pregnancy complications, unskilled ANC provision and lack of tetanus injection were associated with neonatal mortality in Kenya. Integrating community ANC outreach programmes in the national policy strategy and training geared towards early detection of complications can have positive implications for neonatal survival.
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Affiliation(s)
- Malachi Arunda
- a International Master Programme in Public Health, Faculty of Medicine , Lund University, CRC , Malmö , Sweden
| | - Anders Emmelin
- b Social Medicine and Global Health, Department of Clinical Sciences , Lund University , Malmö , Sweden
| | - Benedict Oppong Asamoah
- b Social Medicine and Global Health, Department of Clinical Sciences , Lund University , Malmö , Sweden
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Njagi P, Arsenijevic J, Groot W. Understanding variations in catastrophic health expenditure, its underlying determinants and impoverishment in Sub-Saharan African countries: a scoping review. Syst Rev 2018; 7:136. [PMID: 30205846 PMCID: PMC6134791 DOI: 10.1186/s13643-018-0799-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 08/20/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND To assess the financial burden due to out of pocket (OOP) payments, two mutually exclusive approaches have been used: catastrophic health expenditure (CHE) and impoverishment. Sub-Saharan African (SSA) countries primarily rely on OOP and are thus challenged with providing financial protection to the populations. To understand the variations in CHE and impoverishment in SSA, and the underlying determinants of CHE, a scoping review of the existing evidence was conducted. METHODS This review is guided by Arksey and O'Malley scoping review framework. A search was conducted in several databases including PubMed, EBSCO (EconLit, PsychoInfo, CINAHL), Web of Science, Jstor and virtual libraries of the World Health Organizations (WHO) and the World Bank. The primary outcome of interest was catastrophic health expenditure/impoverishment, while the secondary outcome was the associated risk factors. RESULTS Thirty-four (34) studies that met the inclusion criteria were fully assessed. CHE was higher amongst West African countries and amongst patients receiving treatment for HIV/ART, TB, malaria and chronic illnesses. Risk factors associated with CHE included household economic status, type of health provider, socio-demographic characteristics of household members, type of illness, social insurance schemes, geographical location and household size/composition. The proportion of households that are impoverished has increased over time across countries and also within the countries. CONCLUSION This review demonstrated that CHE/impoverishment is pervasive in SSA, and the magnitude varies across and within countries and over time. Socio-economic factors are seen to drive CHE with the poor being the most affected, and they vary across countries. This calls for intensifying health policies and financing structures in SSA, to provide equitable access to all populations especially the most poor and vulnerable. There is a need to innovate and draw lessons from the 'informal' social networks/schemes as they are reported to be more effective in cushioning the financial burden.
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Affiliation(s)
- Purity Njagi
- United Nations University - Maastricht Economic and social Research institute on Innovation and Technology(UNU-MERIT), Maastricht University, Maastricht, The Netherlands
| | - Jelena Arsenijevic
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Faculty of Law, Economics and Governance, Utrecht University, Utrecht, The Netherlands
| | - Wim Groot
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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