Catastrophic health expenditure and impoverishment in households of persons with depression: a cross-sectional, comparative study in rural Ethiopia

Studying the context of psychoses to improve outcomes in Ethiopia (SCOPE): Protocol paper

BACKGROUND

Global evidence on psychosis is dominated by studies conducted in Western, high-income countries. The objectives of the Study of Context Of Psychoses to improve outcomes in Ethiopia (SCOPE) are (1) to generate rigorous evidence of psychosis experience, epidemiology and impacts in Ethiopia that will illuminate aetiological understanding and (2) inform development and testing of interventions for earlier identification and improved first contact care that are scalable, inclusive of difficult-to-reach populations and optimise recovery.

METHODS

The setting is sub-cities of Addis Ababa and rural districts in south-central Ethiopia covering 1.1 million people and including rural, urban and homeless populations. SCOPE comprises (1) formative work to understand care pathways and community resources (resource mapping); examine family context and communication (ethnography); develop valid measures of family communication and personal recovery; and establish platforms for community engagement and involvement of people with lived experience; (2a) a population-based incidence study, (2b) a case-control study and (2c) a cohort study with 12 months follow-up involving 440 people with psychosis (390 rural/Addis Ababa; 50 who are homeless), 390 relatives and 390 controls. We will test hypotheses about incidence rates in rural vs. urban populations and men vs. women; potential aetiological role of khat (a commonly chewed plant with amphetamine-like properties) and traumatic exposures in psychosis; determine profiles of needs at first contact and predictors of outcome; (3) participatory workshops to develop programme theory and inform co-development of interventions, and (4) evaluation of the impact of early identification strategies on engagement with care (interrupted time series study). Findings will inform development of (5) a protocol for (5a) a feasibility cluster randomised controlled trial of interventions for people with recent-onset psychosis in rural settings and (5b) two uncontrolled pilot studies to test acceptability, feasibility of co-developed interventions in urban and homeless populations.

The burden of health expenditure on household impoverishment in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ethiopia, like many low-income countries, faces significant challenges in providing accessible and affordable healthcare to its population. Health expenditure is a critical factor in determining the quality and accessibility of healthcare. However, high health expenditure can also have detrimental effects on households, potentially leading to impoverishment. To the best knowledge of investigators, no similar study has been conducted in Ethiopia. Therefore, this systematic review and meta-analysis aimed to determine the pooled burden of health expenditure on household impoverishment in Ethiopia.

METHODS

This systematic review and meta-analysis used the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. PubMed, Cochrane Library, HINARI, Google Scholar and Epistemonikos electronic databases were searched systematically. Moreover, direct manual searching through google was conducted. The analysis was performed using STATA version 17 software. Heterogeneity and publication bias were assessed using I2 statistics and Egger's test, respectively. The trim and fill method was also performed to adjust the pooled estimate. Forest plots were used to present the pooled incidence with a 95% confidence interval of meta-analysis using the random effect model.

RESULTS

This systematic review and meta-analysis included a total of 12 studies with a sample size of 66344 participants. The pooled incidence of impoverishment, among households, attributed to health expenditure in Ethiopia was 5.20% (95% CI: 4.30%, 6.20%). Moreover, there was significant heterogeneity between the studies (I2 = 98.25%, P = 0.000). As a result, a random effect model was employed.

CONCLUSION

The pooled incidence of impoverishment of households attributed to their health expenditure in Ethiopia was higher than the incidence of impoverishment reported by the world health organization in 2023.

Do hospitalizations push households into poverty in India: evidence from national data

Introduction

High percentage of OOP (Out-of-Pocket) costs can lead to poverty and exacerbate existing poverty, with 21.9% of India's 1.324 billion people living below the poverty line. Factors such as increased patient cost-sharing, high-deductible health plans, and expensive medications contribute to high OOP costs. Understanding the poverty-inducing impact of healthcare payments is essential for formulating effective measures to alleviate it.

Methods

The study used data from the 75th round of the National Sample Survey Organization (Household Social Consumption in India: Health) from July 2017-June 2018, focusing on demographic-socio-economic characteristics, morbidity status, healthcare utilization, and expenditure. The analysis included 66,237 hospitalized individuals in the last 365 days. Logistic regression model was used to examine the impact of OOP expenditures on impoverishment.

Results

Logistic regression analysis shows that there is 0.2868 lower odds of experiencing poverty due to OOP expenditures in households where there is the presence of at least one child aged 5 years and less present in the household compared to households who do not have any children. There is 0.601 higher odds of experiencing poverty due to OOP expenditures in urban areas compared to households in rural areas. With an increasing duration of stay in the hospital, there is a higher odds of experiencing poverty due to OOP health expenditures. There is 1.9013 higher odds of experiencing poverty due to OOP expenditures if at least one member in the household used private healthcare facility compared to households who never used private healthcare facilities.

Conclusion

In order to transfer demand from private to public hospitals and reduce OOPHE, policymakers should restructure the current inefficient public hospitals. More crucially, there needs to be significant investment in rural areas, where more than 70% of the poorest people reside and who are more vulnerable to OOP expenditures because they lack coping skills.

The association between dual sensory loss and healthcare expenditure: Mediating effect of depression

BACKGROUND

Previous studies have suggested the dual sensory loss (DSL) is linked to depression, and that they are associated with higher healthcare expenditures, respectively. However, the association between DSL, depression and healthcare expenditures remains ambiguous.

OBJECTIVES

The current study aims to examine the association between DSL, depression and healthcare expenditures as well as catastrophic health expenditures (CHE) among Chinese people aged 45 and above.

METHODS

We first utilized the China Health and Retirement Longitudinal Survey (CHARLS) 2018 to obtain data from a total of 13,412 Chinese individuals aged 45 and above to conduct a cross-sectional study. DSL was defined as a combined variable of self-reported vision loss and hearing loss. Depression was measured using The Center for Epidemiologic Studies Depression Scale (CESD-10). The healthcare expenditures, including outpatient out-of-pocket cost and inpatient out-of-pocket cost, were obtained from the Harmonized CHARLS section. CHE were defined as out-of-pocket (OOP) health spending equal to or higher than 40 % of a household's capacity to pay. A Tobit linear regression with three models and a path analysis were conducted to estimate the association between DSL, depression and healthcare expenditures and CHE. Then we utilized 2011CHARLS and 2018CHARLS to present a longitudinal analysis. A path analysis was conducted to estimate the association between 2011DSL, 2018depression and 2018healthcare expenditures and CHE.

RESULTS

Depression has a significant mediating effect between DSL and healthcare expenditures. (For outpatient OOP cost: a = 0.453, b = 23.559, c = 25.257, the proportion of mediating effect in total effect = 29.71 %; for inpatient OOP cost: a = 0.453, b = 13.606, c = 15.463, the proportion of mediating effect in total effect = 28.50 %; all P < 0.05). The mediating effect of depression also exists in the association between DSL and CHE (a = 0.453, b = 0.018, c = 0.043, the proportion of mediating effect in total effect = 15.90 %; P < 0.05). The mediation effect of depression on healthcare expenditures and CHE also exists in the longitudinal analysis using CHARLS 2011 and CHARLS 2018 (all P < 0.05).

LIMITATIONS

The DSL status were based on self-report and we used 2018CHARLS to conduct the study, which may cause some bias.

CONCLUSION

Significant mediating effect of depression exists between DSL and higher healthcare expenditures and CHE. The mental health of elder people with DSL should be focused on, and we should have an overall viewpoint on the topic of healthcare expenditures and CHE.

Catastrophic Health Expenditure and Associated Factors Among Hospitalized Cancer Patients in Addis Ababa, Ethiopia

Background

Out-of-pocket (OOP) health expenditures for cancer care expose households to unanticipated economic consequences. When the available health services are mainly dependent on OOP expenditure, the household faces catastrophic health expenditure (CHE). This study aimed to estimate the incidence and intensity of CHE in hospitalized cancer patients and identify coping strategies and associated factors.

Method and Material

Hospital-based cross-sectional study design was conducted on 305 cancer inpatients in Addis Ababa between November 2021 and February 2022. All patients with cancer who were hospitalized during the data collection period were included in the study. The incidence of CHE was estimated at the 40% threshold of households' non-food expenditure and the intensity of CHE was captured based on the amount by which household expenditure exceeded the threshold and mean positive overshoot, the mean level by which CHE exceeds the threshold used. Multivariate logistic regression was used to assess the relationship between CHE levels and the independent variables.

Results

The incidence of CHE at the 40% threshold of households' non-food expenditure was 77.7%, while the O and MPO were 36.2% and 46.6%, respectively. CHE for cancer care was significantly associated with patient residence, increased number of chemotherapy cycles, increased duration of hospital admission, lack of insurance enrolment, and lower-income quintiles. Saving and selling assets were identified as the primary coping mechanisms.

Conclusion

The incidence and intensity of CHE among inpatients with cancer were high and which could lead to impoverishment of households. Improved quality and coverage of health insurance and decentralizing cancer care to regions standards similar to Addis Ababa will save households from incurring CHE.

Measuring the Effect of Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) on Health Expenditure among Poor Admitted in a Tertiary Care Hospital in the Northern State of India

Background

Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) as a financial risk protection scheme intends to reduce catastrophic health expenditure (CHE), especially among poor. The current study was carried out to assess the utility of AB-PMJAY in terms of reduction in CHE from before and after admission in a tertiary hospital in the northern state of India.

Methodology

It was a hospital-based cross-sectional study carried out from August 2020 to October 2021 at a public tertiary hospital of Himachal Pradesh, India. Data were collected from surgery- and medicine-allied (SA and MA) specialties. Along with socio-demographic details, information for total monthly family expenditure (TMFE), out-of-pocket expenditure (OOPE), and indirect illness-related expenditure (IIE) was recorded before and after hospital admission. CHE was considered as more than 10.0% OOPE of THFE and more than 40.0% of capacity to pay (CTP).

Results

A total of 336 participants with a mean age of 46 years were recruited (MA: 54.6%). The majority (~93.0%) of participants had illness of fewer than 6 months. The mean TMFE was observed to be INR 4213.1 (standard deviation: 2483.7) and found to be similar across specialties. The OOPE share of TMFE declined from 76.1% (before admission) to 30.0% (after admission). Before admission, CHE was found among 65.5% (10.0% of THFE) and 54.2% (40.0% of CTP) participants. It reduced to about 29.0% (based on both THE and CTP) after admission to hospital.

Conclusion

AB-PMJAY scheme found to be useful in reducing CHE in a tertiary hospital.

Magnitude of health expenditure induced removable poverty in India: Some reflections of Ayushman Bharat

The authors have measured the health expenditure-induced removable poverty in India using nationally representative consumer expenditure surveys of three quinquennial rounds conducted by the National Sample Survey Organization (NSSO). This study has also focused on the reflections of Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the world's largest Government-funded health insurance scheme, on these poverty rates in the country. The study has used headcount, payment gap, and concentration index to measure the economic burden and impoverishment impact of out-of-pocket (OOP) health expenditure. The analysis shows that the incidence and depth of poverty are substantially understated because of overlooking OOP health expenditure in the country's standard poverty measure. Outpatient care contributes almost four times more than inpatient care to health expenditure-induced impoverishment in India, though this care has not been covered in the AB-PMJAY. Muslims, among all religious groups, Scheduled Castes among social groups, and casual labourers among different household types are more vulnerable to OOP health expenditure-induced removable poverty in the country. Poverty, in general, has dropped significantly, but the share of health expenditure-induced poverty in general poverty has increased substantially. It has risen considerably in rural areas and among India's most vulnerable sections of society in the past 20 years. We emphasised that universal health insurance coverage is needed in India. Implementing comprehensive health insurance schemes that cover both inpatient and outpatient care can help alleviate the financial burden of healthcare expenses on households and contribute to reducing poverty rates.

Impact of the COVID-19 pandemic on mental health care and people with mental health conditions in Ethiopia: the MASC mixed-methods study

BACKGROUND

The COVID-19 pandemic has had far-reaching effects on the mental health of populations around the world, but there has been limited focus on the impact on people with existing mental health conditions in low-income countries. The aim of this study was to examine impact of the pandemic on mental health care and people with mental health conditions in Ethiopia.

METHODS

A convergent mixed methods study was conducted. We systematically mapped information from publicly available reports on impacts of the pandemic on mental health care. Monthly service utilisation data were obtained from Amanuel Mental Specialised Hospital, the main psychiatric hospital, and analysed using segmented Poisson regression (2019 vs. 2020). In-depth interviews were conducted with 16 purposively selected key informants. Framework analysis was used for qualitative data. Findings from each data source were integrated.

RESULTS

In the early stages of the pandemic, participants indicated a minimal response towards the mental health aspects of COVID-19. Mental health-related stigma and discrimination was evident. Scarce mental health service settings were diverted to become COVID-19 treatment centres. Mental health care became narrowly biomedical with poorer quality of care due to infrequent follow-up. Households of people with pre-existing mental health conditions in the community reported worsening poverty and decreased access to care due to restricted movement, decreased availability and fear. Lack of reliable medication supplies increased relapse and the chance of becoming chained at home, abandoned or homeless. Caregiver burden was exacerbated. Within mental health facilities, prisons and residential units, infection control procedures did not adequately safeguard those with mental health conditions. Meanwhile, the needs of people with mental health conditions in COVID-19 quarantine and treatment facilities were systematically neglected. Only late in the day were integrated services developed to address both physical and mental health needs.

CONCLUSIONS

The COVID-19 pandemic had substantial negative impacts on the lives of people with mental health conditions in Ethiopia. Future emergency response should prioritise the human rights, health, social and economic needs of people with mental health conditions. Integration of mental and physical health care would both expand access to care and increase resilience of the mental health system.

Association of Catastrophic Health Expenditure With the Risk of Depression in Chinese Adults: Population-Based Cohort Study

BACKGROUND

Depression is one of the most common mental illnesses, and it may have a lasting effect on one's whole life. As a form of financial hardship, catastrophic health expenditure (CHE) may be associated with depression. However, current evidence about the relationship between CHE and the risk of depression is insufficient.

OBJECTIVE

This study aimed to explore the relationship between CHE and the risk of depression among Chinese adults.

METHODS

In this study, we used 3 waves of the China Family Panel Studies (CFPS) from 2012, 2016, and 2018. The CFPS are a nationally representative study covering 25 of 31 provinces in Chinese mainland and representing nearly 94.5% of the total population. We selected eligible household heads as participants, divided them into 2 groups by CHE events at baseline (exposed group: with CHE; unexposed group: without CHE), and followed them up. Households with CHE were defined as having out-of-pocket medical expenditures exceeding 40% of the total household nonfood expenditure, and people with depression were identified by the 8-item Centre for Epidemiological Studies Depression Scale (CES-D). We first described the baseline characteristics and used logistical regression to estimate their effects on CHE events. Then, we used Cox proportional hazard models to estimate adjusted hazard ratios and 95% CIs of depression among participants with CHE compared with those without CHE. Finally, we analyzed the subgroup difference in the association between CHE and depression.

RESULTS

Of a total of 13,315 households, 9629 were eligible for analysis. Among them, 6824 (70.9%) were men. The mean age was 50.15 (SD 12.84) years. Only 987 (10.3%) participants had no medical insurance. The prevalence of CHE at baseline was 12.9% (1393/9629). Participants with a higher family economic level (adjusted odds ratio [aOR] 1.15, 95% CI 1.02-1.31) and with the highest socioeconomic development level (aOR 1.18, 95% CI 1.04-1.34) had a higher prevalence of CHE than reference groups. During a median of 71 (IQR 69-72) person-months of follow-up, the depression incidence of participants with CHE (1.41 per 1000 person-months) was higher than those without CHE (0.73 per 1000 person-months). Multivariable models revealed that the adjusted hazard ratio for the incidence of depression in participants with CHE was 1.33 (95% CI 1.08-1.64), and this association appeared to be greater in participants without outpatient services (for interaction, P=.048).

CONCLUSIONS

CHE was significantly associated with increased risk of depression among Chinese adults. Concentrated work should be done to monitor CHE, and more efforts to ensure financial protection need to be made to prevent depression, especially for people with high health care needs.

Perspectives of key decision makers on out-of-pocket payments for medicines in the Ethiopian healthcare system: a qualitative interview study

OBJECTIVE

This study aimed to explore the perspectives of key decision makers on out-of-pocket (OOP) payment for medicines and its implications in the Ethiopian healthcare system.

DESIGN

A qualitative design that employed audiorecorded semistructured in-depth interviews was used in this study. The framework thematic analysis approach was followed in the analysis.

SETTING

Interviewees came from five federal-level institutions engaged in policymaking (three) and tertiary referral-level healthcare service provision (two) in Ethiopia.

PARTICIPANTS

Seven pharmacists, five health officers, one medical doctor and one economist who held key decision-making positions in their respective organisations participated in the study.

RESULT

Three major themes were identified in the areas of the current context of OOP payment for medicines, its aggravating factors and a plan to reduce its burden. Under the current context, participants' overall opinions, circumstances of vulnerability and consequences on households were identified. Factors identified as aggravating the burden of OOP payment were deficiencies in the medicine supply chain and limitations in the health insurance system. Suggested mitigation strategies to be implemented by the health providers, the national medicines supplier, the insurance agency and the Ministry of Health were categorised under plans to reduce OOP payment.

CONCLUSION

The findings of this study indicate that there is widespread OOP payment for medicines in Ethiopia. System level constraints such as weaknesses in the supply system at the national and health facility levels have been identified as critical factors that undermine the protective effects of health insurance in the Ethiopian context. Ensuring steady access to essential medicines requires addressing health system and supply constraints in addition to a well-functioning financial risk protection systems.

Availability, Price and Affordability of Psychotropic Medicines in Addis Ababa, Ethiopia

Background

Access to affordable, quality-assured essential medicines is crucial to reduce the burden of disease. However, one third of the world's population lacks regular access to essential medicines. The purpose of this study was to assess the availability, price, and affordability of medicines for mental disorders in Addis Ababa, Ethiopia.

Methods

A cross-sectional study was done in selected pharmacies after modification of a WHO/HAI methodology developed questionnaire. Data on the availability and price of 28 lowest priced generics and originator brand essential psychotropic medicines were collected from seven public sectors, five private sectors, and seven other sectors (five Kenema Public Community Pharmacies and two Red Cross Pharmacies) in Addis Ababa between May 9 and May 31, 2022. The data were analyzed using the developed WHO/HAI workbook part I Excel sheet. Descriptive results were reported in text and table format.

Results

The overall availability of lowest-priced generics medication was 41.69%. The availability of lowest-priced generics and originator brand medication was 54.68% and 1.7% in the public pharmacies; 24.14% and 0.0% in private pharmacies; 43% and 0.0% in Red Cross Pharmacies; and 42% and 3.2% in Kenema Public Community Pharmacies. The median price ratio in the public, private, Red Cross, and Kenema Public Community pharmacies was 1.26, 3.72, 1.65, and 1.59, respectively. Most of the medications were unaffordable. A patient could be required to pay up to 73 days wages to purchase a standard treatment for 1 month.

Conclusion

The availability of psychotropic medicines was lower than the WHO target for non-communicable diseases and most of the available medicines were unaffordable.

The financial burden of out of pocket payments on medicines among households in Ethiopia: analysis of trends and contributing factors

BACKGROUND

In Ethiopia, out-of-pocket (OOP) payment is the key means of healthcare financing, and expenses on medicines are a crucial component of such payment. This study aims to investigate the financial implications of OOP payments on medicines for Ethiopian households.

METHODS

The study involved a secondary data analysis of the national household consumption and expenditure surveys of 2010/11 and 2015/16. The "capacity-to-pay" method was used to calculate catastrophic OOP medicine expenditures. The extent of economic status related to catastrophic medicine payment inequity was calculated using concentration index estimation. The impoverishment consequences of OOP payment on medicine were estimated using poverty headcount and poverty gap analysis methods. Logistic regression models were used to identify the variables that predict catastrophic medicine payments.

RESULTS

Medicines accounted for the majority of healthcare spending (> 65%) across the surveys. From 2010 to 2016, the total percentage of households facing catastrophic medicine payments decreased from 1% to 0.73%. However, the actual number of people expected to have experienced catastrophic medicine payments increased from 399,174 to 401,519 people. Payment for medicines pushed 11,132 households into poverty in 2015/16. The majority of disparities were explained by economic status, place of residence, and type of health services.

CONCLUSION

OOP payment on medicine accounted for the majority of total health expenses in Ethiopia. A high medicine OOP payment continued to push households into catastrophic payments and impoverishment. Household seeking inpatient care, those with lower economic status and urban residents were among the most affected. Hence, innovative approaches to improve the supply of medicines in public facilities especially those in urban settings and risk protection mechanisms for medicine expenditures particularly for inpatient care are recommended.

Catastrophic health expenditures in hospitalized patients with delta variant of COVID-19: A cross-sectional study

Background: Financial protection of populations against healthcare costs is one of the fundamental responsibilities of governments. This study aimed to investigate the incidence of catastrophic health expenditures (CHE) and it's affecting factors in hospitalized patients with delta variant of COVID-19. Methods: In this cross-sectional study, we included 400 hospitalized COVID-19 patients at Kosar Hospital of Semnan in 2022, using a researcher-made checklist. Based on qualitative nature of the variables, chi-square test was used to investigate the statistical associations between the demographic/background characteristics and the incidence of CHE. Results: On average, COVID-19 imposed 1833.43 USD direct medical costs per one hospitalized patient. The ratio of direct-medical costs to household's non-food expenses was 2.35, and 61% (CI:±4.78%) of the patients were subject to CHE. Besides, residence place, basic insurance type, benefitting from supplementary insurance, suffering from underlying diseases, hospitalization in ICU, falling into a coma, facing pulmonary failure, and performing hemoperfusion had significant associations with CHE (P<0.05). Conclusion: The incidence of CHE in hospitalized COVID-19 patients was undesirable, which may be due to geographical, economical, and occupational inequalities apart from the factors related to the severity of the disease. So, health policymakers should pay attention to the provision of proper financial risk protection policies to make the health insurance system more efficient and appropriate.

Leaving no one behind in health: Financial hardship to access health care in Ethiopia

BACKGROUND

Financial hardship (of health care) is a global and a national priority area. All people should be protected from financial hardship to ensure inclusive better health outcome. However, financial hardship of healthcare has not been well studied in Ethiopia in general and in Debre Tabor town in particular. Therefore, this study aimed to assess the incidence of financial hardship of healthcare and associated factors among households in Debre Tabor town.

METHODS

Community based cross sectional study was conducted, from May 24/2022 to June 17/2022, on 423 (selected through simple random sampling) households. Financial hardship was measured through catastrophic (using 10% threshold level) and impoverishing (using $1.90 poverty line) health expenditures. Patient perspective bottom up and prevalence based costing approach were used. Indirect cost was estimated through human capital approach. Bi-variable and multiple logistic regressions were used.

RESULTS

The response rate was 95%. The mean household annual healthcare expenditure was Ethiopian birr 12050.64 ($227.37). About 37.1% (95%CI: 32, 42%) of the households spend catastrophic health expenditure with a 10% threshold level and 10.4% of households were impoverished with $1.90 per day poverty line. Being old, with age above 60, (AOR: 4.21, CI: 1.23, 14.45), being non-insured (AOR: 2.19, CI: 1.04, 4.62), chronically ill (AOR: 7.20, CI: 3.64, 14.26), seeking traditional healthcare (AOR: 2.63, CI: 1.37. 5.05) and being socially unsupported (AOR: 2.77, CI: 1.25, 6.17) were statistically significant factors for catastrophic health expenditure.

CONCLUSION

The study showed that significant number of households was not yet protected from financial hardship of healthcare. The financial hardship of health care is stronger among the less privileged populations: non-insured, the chronically diseased, the elder and socially unsupported. Therefore, financial risk protection strategies should be strengthened by the concerned bodies.

Healthcare use and costs among individuals receiving mental health services for depression within primary care in Nepal

BACKGROUND

Integrating mental health services into primary care is a key strategy for reducing the mental healthcare treatment gap in low- and middle-income countries. We examined healthcare use and costs over time among individuals with depression and subclinical depressive symptoms in Chitwan, Nepal to understand the impact of integrated care on individual and health system resources.

METHODS

Individuals diagnosed with depression at ten primary care facilities were randomized to receive a package of integrated care based on the Mental Health Gap Action Programme (treatment group; TG) or this package plus individual psychotherapy (TG + P); individuals with subclinical depressive symptoms received primary care as usual (UC). Primary outcomes were changes in use and health system costs of outpatient healthcare at 3- and 12-month follow up. Secondary outcomes examined use and costs by type. We used Poisson and log-linear models for use and costs, respectively, with an interaction term between time point and study group, and with TG as reference.

RESULTS

The study included 192 primary care service users (TG = 60, TG + P = 60, UC = 72; 86% female, 24% formally employed, mean age 41.1). At baseline, outpatient visits were similar (- 11%, p = 0.51) among TG + P and lower (- 35%, p = 0.01) among UC compared to TG. Visits increased 2.30 times (p < 0.001) at 3 months among TG, with a 50% greater increase (p = 0.03) among TG + P, before returning to baseline levels among all groups at 12 months. Comparing TG + P to TG, costs were similar at baseline (- 1%, p = 0.97) and cost changes did not significantly differ at three (- 16%, p = 0.67) or 12 months (- 45%, p = 0.13). Costs among UC were 54% lower than TG at baseline (p = 0.005), with no significant differences in cost changes over follow up. Post hoc analysis indicated individuals not receiving psychotherapy used less frequent, more costly healthcare.

CONCLUSION

Delivering psychotherapy within integrated services for depression resulted in greater healthcare use without significantly greater costs to the health system or individual. Previous research in Chitwan demonstrated psychotherapy determined treatment effectiveness for people with depression. While additional research is needed into service implementation costs, our findings provide further evidence supporting the inclusion of psychotherapy within mental healthcare integration in Nepal and similar contexts.

Factors associated with catastrophic health expenditure in sub-Saharan Africa: A systematic review

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.

Financial Risk Protection and Unmet Healthcare Need in Russia

BACKGROUND

Achieving universal health coverage (UHC) includes financial risk protection. To date, catastrophic healthcare expenditure (CHE), the impoverishing effect of out-of-pocket (OOP) healthcare payments, and unmet healthcare need are the most widely used indicators for assessing the financial risk protection of a healthcare system. This study aimed to estimate the Russian healthcare system's financial risk protection by focusing on CHE, OOP and unmet healthcare need.

METHODS

The study used eight waves of the Russia Longitudinal Monitoring Survey (RLMS) (2010-2017) to analyze the financial risk protection of the Russian healthcare system. Commonly used indicators - CHE, both incidence and intensity, the impoverishing effect of CHE and unmet need -were used.

RESULTS

We found low incidence and intensity of CHE in the Russian Federation. Our results are robust to various definitions of CHE (eg, as a share of total household expenditure or total household income). Furthermore, the impoverishing effect of OOP healthcare payments remains limited, despite the most recent economic slowdown (2014- 2016). This could be explained by a noticeable reduction in CHE during the crisis years, as postponing healthcare was adopted as a coping mechanism, particularly among households heavily affected by the crisis.

CONCLUSION

As stressed by the UHC framework, our findings suggest that CHE only partly captures inefficiencies and inequities in coverage, because one tenth of households forwent medical care for medicines and certain services. As spending on medicines and dental care are the main drivers of CHE, policy interventions should focus on extending coverage for pharmaceutical and dental care and target financial barriers to seeking care, particularly for the poor and vulnerable.

The true costs of cesarean delivery for patients in rural Rwanda: Accounting for post-discharge expenses in estimated health expenditures

Introduction

While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda.

Methods

We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05.

Results

Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91).

Conclusion

Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis

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.

A 25-Year Trend of Catastrophic Health Expenditure and Its Inequality in China: Evidence from Longitudinal Data

Purpose

The Chinese government has carried out two major cycles of reform to improve the health system and reduce the disease burden on residents. This study aims to comprehensively track the trends in the occurrence of catastrophic health expenditure (CHE) and its inequality in the past 25 years, which may help better understand the influence of health system reforms on CHE and its inequality.

Methods

The study employed the subset of data from China Health and Nutrition Survey conducted from 1991 to 2015. Health payments and net household income were used to calculate CHE. Concentration index and decomposition analysis were used to measure the magnitude of income-related inequality in CHE and decompose it into determinants, respectively.

Results

The incidence of CHE in China increased from 3.10% in 1993 to 8.90% in 2004 and still maintained at a high level in the following years. The incidence gap of CHE between the richest and poorest became increasingly wider over year. Moreover, the values of adjusted concentration indexes were all negative in each year, decreasing from −0.202 in 1991 to −0.613 in 2015. Income was consistently the largest contributor to the inequality in CHE. The basic medical insurance did not decrease the incidence of CHE and showed the second largest contribution on its inequality before 2004. However, this contribution began to decline after 2006.

Conclusion

After the New Health Care Reform, despite many measures taken by the Chinese government, there was still a high incidence of CHE and an increasing inequality from 1991 to 2015. The basic medical insurance in China was not enough to protect households from CHE. The use of big data tools and techniques to effectively screen the poor households, and strengthening the social medical aid system would be helpful to decrease the inequality in CHE.

How Do Intergenerational Economic Support, Emotional Support and Multimorbidity Affect the Catastrophic Health Expenditures of Middle-Aged and Elderly Families?–Evidence From CHARLS2018

Objectives

The elderly face multiple vulnerabilities such as health, economy and society, and are prone to catastrophic health expenditures. This study aims to analyze the impact of children's intergenerational economic support, emotional support, and illness on the catastrophic health expenditures of middle-aged and elderly families.

Methods

Using China Health and Retirement Longitudinal Study (CHARLS 2018) data to calculate the catastrophic health expenditure of Chinese households as the dependent variable. Taking children's intergenerational economic support, emotional support and multimorbidity as core independent variables, gender, age, marital status, medical insurance and other variables as control variables, and perform logistic regression analysis. According to the heterogeneity analysis of age and gender, the impact of intergenerational economic support, emotional support and multimorbidity on the catastrophic health expenditure of middle-aged and elderly families is explored.

Results

When catastrophic health expenditures occur in middle-aged and elderly families, the children's intergenerational economic support will increase significantly, especially in families with members aged 60–74. Children's emotional support can effectively reduce the risk of catastrophic health expenditures for middle-aged and elderly families. Compared with children's intergenerational economic support and emotional support, the impact of multimorbidity on the catastrophic health expenditures of middle-aged and elderly families is the most significant. Suffering from multimorbidity can increase the risk of catastrophic health expenditures for middle-aged and elderly families, especially families with male members suffering from multiple diseases.

Conclusions

It is recommended that we should do a good job in popularizing the knowledge of chronic diseases to minimize the occurrence of multimorbidity. The government should establish group medical insurance related to chronic disease diagnosis. According to the severity of the disease or the special circumstances of the patient, the level of medical insurance reimbursement is divided in detail, especially for chronic disease clinics and drug reimbursement. Children should be encouraged to strengthen the emotional connection and effective care of the elderly, focusing on the elderly 60–74 years old, in order to reduce their care pressure and maintain the physical and mental health of the elderly.

The burden of household out-of-pocket healthcare expenditures in Ethiopia: a systematic review and meta-analysis

BACKGROUND

In Ethiopia, household Out-Of-Pocket healthcare expenditure accounts for one-third of total healthcare expenditure, is one of the highest in the world, and still creates barriers and difficulties for households to healthcare access and may delay or forgo needed healthcare use. Despite the presence of a few highly dispersed and inconsistent studies, no comprehensive study was conducted. Therefore, in this systematic review and meta-analysis, we aimed at estimating the pooled estimates of the burden of household Out-Of-Pocket healthcare expenditures among Ethiopian households and identifying its determinants.

METHODS

We systematically searched articles from PubMed / Medline and Google scholar databases and direct Google search engine without restriction on publication period. Cross-sectional and cohort articles and grey literature published in English were included. Data were extracted using Microsoft Excel. Two reviewers screened the titles, reviewed the articles for inclusion, extracted the data, and conducted a quality assessment. The third reviewer commented on the review. Articles with no abstracts or full texts, editorials, and qualitative in design were excluded. To assess quality, Joanna Briggs Critical Appraisal Tools was used. A Forest plot was used to present summary information on each article and pooled common effects. Potential heterogeneity was checked using Cochrane's Q test and I-squared statistic. We checked publication bias using a Funnel plot. Moreover, subgroup and sensitivity analyses were performed. Meta-analysis was used for the pooled estimates using RevMan statistical software Version 5.4.1.

RESULTS

In this review, a total of 27 primary articles were included (with a total sample size of 331,537 participants). Because of the presence of heterogeneity, we employed a random-effects model; therefore, the pooled burden household Out-Of-Pocket / catastrophic healthcare expenditure in Ethiopia was strongly positively associated with household economic status. The odds of facing Out-Of-Pocket / catastrophic healthcare expenditures among the poorest quintile was about three times that of the richest (AOR = 3.09, 95% CI: 1.63, 5.86) p-value < 0.001. In addition, on pooled analysis, the mean direct Out-Of-Pocket healthcare expenditures were $32 per month (95%CI: $11, $52) (SD = $45), and the mean indirect Out-of-Pocket healthcare expenditures were $15 per month (95%CI: $3, $28) (SD = $17). The mean catastrophic healthcare expenditure at 10% of threshold was also disproportionately higher: 40% (95%CI: 28, 52%) (SD = 20%). Moreover, the common coping mechanisms were a sale of household assets, support from family, or loan: 40% (95%CI: 28, 52%) (SD = 20%).

CONCLUSION

Our study revealed the evidence of inequity in financial hardship that the burden of household Out-Of-Pocket / catastrophic healthcare expenditures gap persists among Ethiopian households that is unfair and unjust. To reduce the detected disparities in seeking healthcare among Ethiopian households, national healthcare priorities should target poor households. This calls for the Ministry of Health to improve the challenges and their impact on equity and design better prepayment policies and strengthen financial protection strategies to protect more vulnerable Ethiopian households.

PROTOCOL REGISTRATION

The details of this protocol have been registered on the PROSPERO database with reference number ID: CRD42021255977 .

[Catastrophic expenditure on congenital Zika syndrome: results of a cross-sectional study of caregivers of children in Rio de Janeiro, Brazil]

In 2015, there was an increase in cases of congenital malformations in newborns in Brazil, associated with maternal Zika virus infection, having serious social and economic repercussions for the families. The study aimed to estimate the prevalence of catastrophic expenditure by families of children with severe or mild/moderate congenital Zika syndrome (CZS) in comparison to families of children without a diagnosis of CZS in the state of Rio de Janeiro. Catastrophic expenditure occurs when spending exceeds a given proportion of the family income due to a disease. Family caregivers of children with severe CZS were younger and had less schooling and lower income. Prevalence of catastrophic expenditure was higher in families of children with CZS. Among caregivers of children with severe CZS, the prevalence of catastrophic expenditure was higher in those with severe or very severe depression, anxiety, and stress. Low social support among caregivers was also a determinant factor for increased prevalence of catastrophic expenditure. The burden on caregivers of children with severe CZS exacerbates a situation of vulnerability that requires the expansion of mechanisms for financial and social protection, through linkage of various policies capable of effectively reaching this group.

Multidimensional and intergenerational impact of Severe Mental Disorders

BACKGROUND

Severe Mental Disorders (SMDs) affect multiple generations although this is poorly studied. The aim of this study was to investigate the intergenerational and multidimensional impacts of SMD in rural Ethiopia.

METHODS

This comparative study was nested within an existing population-based cohort study. We collected data from a total 5762 family members of 532 households (266 households with at least one family member with SMD and 266 sex and age matched mentally well controls from the neighborhood) in 2019. The main outcomes were multidimensional poverty, mortality, food insecurity, and family satisfaction.

FINDINGS

Multidimensional poverty Index was higher in the households of persons with SMD (74·44%) than the comparison households (38·35%). School attendance was lower in children of people with SMD (63·28%) than children of the comparisons (78·08%). The median years of schooling was also lower among children of people with SMD than the controls. This lower attendance was also true among siblings of people with SMD (35·52%) than the comparisons (49·33%). Over the course of 20 years, family members who have a person with SMD in their household had 23% increased risk of death compared to family members who did not have a person with SMD in their household. Severe food insecurity was also higher in the SMD households (20·68%) than the comparison (13·53%) while family satisfaction was lower.

INTERPRETATION

Families of people with SMD experience pervasive multidimensional and intergenerational impacts. Interventions should consider the broader family social and healthcare needs of the broader family.

Depression in Ugandan Rural Women Involved in a Money Saving Group: The Role of Spouse's Unemployment, Extramarital Relationship, and Substance Use

Background

Rural women are highly prevalent to depression, where spouse-related factors, including extramarital affairs and poverty, intensify its likelihood of occurrence. However, women engaged with a Money-Saving Group (MSG) are financially self-dependent, which can reduce the risk of depression suffering. Despite this, there is less study among this cohort, which led us to investigate the prevalence and associated factors of depression among the Ugandan women involved in MSG.

Methods

This was a cross-sectional study in Uganda among rural married or cohabiting women aged 18 to 45 years engaged in MSG. The survey was carried out within a total of 153 participants (33.3 ± 6.7 years) in April 2021. Information related to socio-demographic of the participants, their spouse characteristics, and depression were collected.

Results

About 65.4% of the participants had depressive symptoms (based on the cutoff 10/27 at the PHQ-9). But, 8.15 times (CI: 2.83–23.44, p<0.001) and 16.69 times (CI: 4.85–57.39, p<0.001), higher risk of depression were observed, if the participants’ spouses were using an addictive substance and had been involved in an extramarital relationship, respectively. Similarly, there was an increased likelihood of depression when the participant or spouse was unemployed.

Conclusion

This study observed a higher prevalence of depression, which suggests paying attention to this cohort. Thus, there should be routine screening for depression among married women involved in MSG at lower-level health facilities in rural settings, especially those with spouses engaged in substance use, having an extramarital relationship, and being unemployed.

Catastrophic health expenditures for children with disabilities in Iran: A national survey

OBJECTIVE

The aim of this study was to investigate the percentage of households with disabled children aged 0-8 years who had faced catastrophic health expenditures (CHEs) due to the health costs of these children in Iran.

METHODS

This cross-sectional study was carried out on 2000 households with disabled children aged 0-8 years in five provinces of Iran in 2020. Data were collected using the World Health Survey questionnaire and face-to-face interview. Determinants of CHE were identified using logistic regression.

RESULTS

32.7% of households with disabled children had faced CHE. Head of household being female (Adjusted OR = 18.89, 95%CI: 10.88-29.42), poor economic status of the household (Q1: Adjusted OR = 20.26, 95% CI, 11.42-35.94; Q2: Adjusted OR = 8.27, 95%CI, 4.45-15.36; Q3: Adjusted OR = 13.88, 95%CI, 7.89-24.41), lack of supplementary insurance by a child with disabilities (Adjusted OR = 6.13, 95%CI, 3.39-11.26), having a child with mental disability (Adjusted OR = 2.71, 95%CI, 1.60-4.69), and type of basic health insurance (having Iranian Health Insurance: Adjusted OR = 2.20, 95%CI, 1.38-3.49; having Social security insurance: Adjusted OR = 1.66, 95%CI, 1.06-2.61) significantly increased the chances of facing CHE.

CONCLUSION

A significant percentage of households with disabled children had faced CHE because of their disabled child's health costs. The key determinants of CHE should be considered by health policy-makers in order to more financial protection of these households.

Health System Capacity and Access Barriers to Diagnosis and Treatment of CVD and Diabetes in Nepal

Background:

Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions availability, affordability, accessibility, acceptability, and quality is crucial yet rarely performed, especially in low- and middle-income countries.

Objective:

To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal.

Methods:

We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public-sector: 11; private-sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during MayJuly 2017. Data for 13 routine diagnostics was obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 days wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepals adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality.

Results:

We found that mean availability of generic medicines is low (<50%) in both public and private sectors, and less than one-third medicines met WHOs availability target (80%). Mean (SD) availability of diagnostics was 73.1% (26.8%). Essential medicines appear locally unaffordable. On average, the lowest-paid worker would spend 1.03 (public-sector) and 1.26 (private-sector) days wages to purchase a monthly supply. For a person undergoing CVD secondary preventive-interventions in the private sector, the associated expenditure would be 7.511.2% of monthly household income. Exit-interviews suggest that a long/expensive commute to health-facilities and poor medicine affordability constrain access.

Conclusions:

This study highlights critical gaps in Nepals health system capacity to offer basic health services to CVD and diabetes patients, owing to low availability, poor affordability and accessibility of essential medicines and diagnostics. Research and policy initiatives are needed to ensure uninterrupted supply of affordable essential medicines and diagnostics.

Are Ethiopian diabetic patients protected from financial hardship?

Background

Globally, diabetes mellitus exerts an economic burden on patients and their families. However, the economic burden of diabetes mellitus and its associated factors were not well studied in Ethiopia. Therefore, the aim of this study is to assess the economic burden of diabetes mellitus and its associated factors among diabetic patients in public hospitals of Bahir Dar city administration, Ethiopia.

Methods

Across sectional study was conducted on 422 diabetic patients. The patients were selected by simple random sampling method. The prevalence-based model was used to estimate the costs on patients’ perspective. Bottom up and human capital approaches were used to estimate the direct and indirect costs of the patients respectively. Wealth index was constructed using principal component analysis by SPSS. Forty percent of nonfood threshold level was used to measure catastrophic diabetic care expenditure of diabetic patients. Whereas, the World Bank poverty line (the $1.90-a-day poverty line) was used to measure impoverishment of patients due to expenses of diabetes mellitus care. Data were entered by Epi data version 3.1and exported to SPSS version 23 for analysis. Simple and multiple logistic regressions were used.

Results

Four hundred one respondents were interviewed with response rate of 95%. We found that 239 (59.6%) diabetic patients incurred catastrophic diabetic care expenditure at 40% nonfood threshold level. Whereas, 20 (5%) diabetic patients were impoverished by diabetic care spending at the $1.90-a-day poverty line. Educational status of respondent, educational status of the head of household, occupation and wealth status were statistically associated with the catastrophic diabetic care expenditure.

Conclusions

The study revealed that the economic burden of diabetic care is very disastrous among the less privileged populations: the less educated, the poorest and unemployed. Therefore, all concerned stakeholders should design ways that can reduce the financial hardship of diabetic care among diabetic patients.

Does the type of health insurance enrollment affect provider choice, utilization and health care expenditures?

BACKGROUND

Two of the objectives of Universal Health Coverage are equity in access to health services and protection from financial risks. This paper seeks to examine whether the type of health insurance enrollment affects the utilization of health services, choice of provider and financial protection of households in Togo.

METHODS

Data were obtained from a cross-sectional, representative household survey involving 1180 insured households that had reported either illness in the household in the 4 weeks preceding the survey or hospitalization in the 12 months preceding the survey. A nested logit model was used to account for the utilization of health services and provider choice, and methods of assessing catastrophic health care expenditures were used to analyze the level of household financial protection.

RESULTS

Policyholders of private health insurance use private health care facilities more than policyholders of public health insurance. The main reasons for not using health centers among households with public insurance were out-of-pocket payments (49.19%), waiting time (36.80%), and distance to the nearest health center (36.76%). Furthermore, on average, households with public insurance spent a higher proportion of their total monthly nonfood expenditures on health care than those with private insurance. We find that the type of insurance, share of expenditures allocated to food, distance to the nearest health center, and waiting time significantly impact the choice of provider. Regardless of the type of health insurance, elderly individuals avoid using private health centers and referral hospitals due to the high cost.

CONCLUSION

We found that a multiple health insurance system results in a multilevel health system that is not equitable for everyone. The capacity of the health insurance system to provide equitable health care services and protect its members from catastrophic health care expenditures should be at the core of health care reform. This study recommends raising awareness of the criteria for the reimbursement of medical procedures within the framework of public insurance and promoting specific health insurance mechanisms for elderly individuals. Careful attention should be paid to ensuring universal education and literacy as a means of improving access to and the use of health care.

Trend and status of out-of-pocket payments for healthcare in Iran: equity and catastrophic effect

Background

Equity in the distribution of health care resources and mitigating the risk of out-of-pocket (OOP) catastrophic healthcare expenditures (CHE) are the major objectives of the health system of a country. This study aims to measure equity in OOP payments for healthcare and the incidence of CHE among Iranian households over time.

Methods

This retrospective cross-sectional study utilized data extracted from the household income and expenditure survey (HIES) of Iran, collected by the Statistical Center of Iran. The analysis included a total of 174,341 households’ five yearly data of 6 years starting from 1991 to 2017. Kakwani progressivity index (KPI) was used to measure the equity in OOP payment for each year and examine the households’ incidence of CHE at 20%, 30%, and 40% of their capacities to pay (CTP). The trend series regression analysis was used to examine the trend in the KPI and the incidence of the CHE over time.

Results

The findings indicated that the households’ expenditure on health out of their monthly budgets for the years 1991 and 2017 were 2.1% and 10.1%, respectively. The KPI for the OOP payment was negative for all 6-year observations (1991 = − 0.680; 1996 = − 0.608; 2001 = − 0.554; 2006 = − 0.265; 2011 = − 0.225, and 2017 = − 0.207), indicating that the OOP payments for healthcare are regressive and more concentrated among the socioeconomically disadvantaged households. There was a statistically significant (p = 0.003) increase in the KPI (i.e., decline in the regressivity) over time. The incidence of the CHE (1.12, 1.93, and 3.71%) in 1991 at the CTP levels of 20%, 30%, and 40% was lower than the incidence at the corresponding levels of CTP (5.26, 10.88, and 22.16) in 2017. The findings of the time-series regression indicated a statistically significant (p < 0.05) increase in the incidence of the CHE at the 20%, 30%, and 40% levels of the households’ CTP.

Conclusions

The current study demonstrated that OOP payment as a source of healthcare funding in Iran is inequitable. While the use of interventions such as the prepaid and publicly funded programs may contribute to the reduction of CHE and improvement of equity in healthcare financing, further inequality analyses in the incidence of the CHE among households and its main determinants can contribute to evidence-informed planning to reduce the CHE in the context.

Primary health care contributions to universal health coverage, Ethiopia

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population’s health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.

Catastrophic healthcare expenditure and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia

BACKGROUND

With the rapid increase in magnitude and mortality of cancer, which is costly disease to manage, several patients particularly in developing countries are facing a huge financial burden. The study aimed to examine the incidence of catastrophic health expenditure (CHE), identify associated factors and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia.

METHODS

A hospital-based cross-sectional survey of patients with cancer was conducted in public and private hospitals between January and March 2018. Data was collected using a structured questionnaire. All direct medical and nonmedical expenditures were measured and reported as expenditure (US$) per patient (1US$ equivalent to 23.41 Ethiopian Birr). The CHE was estimated using a threshold of 10% of annual household income.

RESULTS

A total of 352 (response rate of 87.1%) participants were interviewed. Majority (73.3%) of the respondents were females; most (94%) from public hospitals and their mean (±SD) age was 48 ± 13.2 years. Vast majority (74.4%) of patients experienced CHE with mean overall expenditure of $2366 per patient (median: $1708). Medical expenditure shared the highest overall expenditure (83.6%) with mean medical and nonmedical costs of $1978 (median: $1394) and $388 (median: $222), respectively. Patients who took greater than six cycles of chemotherapy (AOR: 3.64; 95% CI: 1.11-11.92), and age (AOR: 1.03; 95% CI: 1.01-1.06) were significantly associated with CHE. Household saving (85.5%) followed by financial support received (43.0%) was the main coping strategy.

CONCLUSION

A substantial number of patients with cancer were exposed to CHE with a considerable medical expenditure. Hence, in addition to the popularization of the already introduced health insurance scheme, other better prepayment or insurance mechanisms should also be considered to ensure financial risk protection and realize universal health coverage for patients with cancer.

Financial risk of seeking maternal and neonatal healthcare in southern Ethiopia: a cohort study of rural households

INTRODUCTION

Ethiopian households' out-of-pocket healthcare payments constitute one-third of the national healthcare budget and are higher than the global and low-income countries average, and even the global target. Such out-of-pocket payments pose severe financial risks, can be catastrophic, impoverishing, and one of the causal barriers for low utilisation of healthcare services in Ethiopia. This study aimed to assess the financial risk of seeking maternal and neonatal healthcare in southern Ethiopia.

METHODS

A population-based cohort study was conducted among 794 pregnant women, 784 postpartum women, and their 772 neonates from 794 households in rural kebeles of the Wonago district, southern Ethiopia. The financial risk was estimated using the incidence of catastrophic healthcare expenditure, impoverishment, and depth of poverty. Annual catastrophic healthcare expenditure was determined if out-of-pocket payments exceeding 10% of total household or 40% of non-food expenditure. Impoverishment was analysed based on total household expenditure and the international poverty line of ≈ $1.9 per capita per day.

RESULTS

Approximately 93% (735) of pregnant women, 31% (244) of postpartum women, and 48% (369) of their neonates experienced illness. However, only 56 households utilised healthcare services. The median total household expenditure was $527 per year (IQR = 390: 370,760). The median out-of-pocket healthcare payment was $46 per year (IQR = 46: 46, 92) with two episodes per household, and shared 19% of the household's budget. The poorer households paid more than did the richer for healthcare, during pregnancy-related and neonatal illness. However, the richer paid more than did the poorer during postpartum illness. Forty-six percent of households faced catastrophic healthcare expenditure at the threshold of 10% of total household expenditure, or 74% at a 40% non-food expenditure, and associated with neonatal illness (aRR: 2.56, 95%CI: 1.02, 6.44). Moreover, 92% of households were pushed further into extreme poverty and the poverty gap among households was 45 Ethiopian Birr per day. The average household size among study households was 4.7 persons per household.

CONCLUSIONS

This study demonstrated that health inequity in the household's budget share of total OOP healthcare payments in southern Ethiopia was high. Besides, utilisation of maternal and neonatal healthcare services is very low and seeking such healthcare poses a substantial financial risk during illness among rural households. Therefore, the issue of health inequity should be considered when setting priorities to address the lack of fairness in maternal and neonatal health.

Causal mechanisms of postnatal depression among women in Gondar town, Ethiopia: application of a stress-process model with generalized structural equation modeling

BACKGROUND

Postnatal depression (PND) is the second most common cause of disability and the most common complication after childbirth. Understanding the potential mechanisms by which the stress process can lead to PND is an important step for planning preventive interventions for PND. This study employed a stress process model to explore the possible pathways leading to PND in Gondar Town, Ethiopia.

METHODS

A community-based cohort study was conducted in 916 pregnant women, who were assessed for depression in their second or third trimester of pregnancy and re-assessed two to eight weeks after birth. Women with an Edinburgh Postnatal Depression Scale (EPDS) ≥6 were considered to be depressed. Modified Poisson regression was used to identify the independent predictors of PND. A Generalized Structural Equation Modeling (GSEM) was then used to explore the direct and indirect effects of stressors and their mediators on PND.

RESULTS

The prevalence and incidence proportion of PND were 9.27% (95%CI: 7.45, 11.36) and 7.77% (95%CI: 6.04, 9.79), respectively and 2.1% of the women demonstrated symptoms of depression within the study period. PND was independently predicted by having limited postnatal care services, Antenatal Depression (AND) and a Common Mental Disorders (CMD) before pregnancy, (IRR = 1.8; 95%CI: 1.0, 3.2), 1.6(95%CI: 1.4, 1.7), and 2.4 (95%CI: 1.4, 4.3) respectively). In SEM, AND (standardized total effect = 0.36) and a CMD before pregnancy (standardized total effect = 0.11) had both a direct and an indirect positive effect on PND scores. Low birth weight (standardized β = 0.32) and self-reported labor complications (standardized β = 0.09) had direct effects only on PND scores.

CONCLUSION

The observed incidence and prevalence of PND in Ethiopia were lower than in previous studies. A CMD before pregnancy and low birth weight (LBW) increased PND scores, and these effects were in part mediated via antenatal depression and labor complications. Early detection and treatment of depression before or during pregnancy could either directly or indirectly reduce the risk of labor complications and PND. Interventions that reduce LBW or improve the uptake of postnatal care might reduce PND incidence.

Assessing medical impoverishment and associated factors in health care in Ethiopia

BACKGROUND

About 5% of the global population, predominantly in low- and middle-income countries, is forced into poverty because of out-of-pocket (OOP) health spending. In most countries in sub-Saharan Africa, the share of OOP health spending in current health expenditure exceeds 35%, increasing the likelihood of impoverishment. In Ethiopia, OOP payments remained high at 37% of current health expenditure in 2016. This study assesses the impoverishment resulting from OOP health spending in Ethiopia and the associated factors.

METHODS

This paper uses data from the Ethiopian Household Consumption Expenditure Survey (HCES) 2010/11. The HCES covered 10,368 rural and 17,664 urban households. OOP health spending includes spending on various outpatient and inpatient services. Impoverishing impact of OOP health spending was estimated by comparing poverty estimates before and after OOP health spending. A probit model was used to assess factors that are associated with impoverishment.

RESULTS

Using the Ethiopian national poverty line of Birr 3781 per person per year (equivalent to US$2.10 per day), OOP health spending pushed about 1.19% of the population (i.e. over 957,169 individuals) into poverty. At the regional level, impoverishment ranged between 2.35% in Harari and 0.35% in Addis Ababa. Living in rural areas (highland, moderate, or lowland) increased the likelihood of impoverishment compared to residing in an urban area. Households headed by males and adults with formal education are less likely to be impoverished by OOP health spending, compared to their counterparts.

CONCLUSION

In Ethiopia, OOP health spending impoverishes a significant number of the population. Although the country had piloted and initiated many reforms, e.g. the fee waiver system and community-based health insurance, a significant proportion of the population still lacks financial protection. The estimates of impoverishment from out-of-pocket payments reported in this paper do not consider individuals that are already poor before paying out-of-pocket for health services. It is important to note that this population may either face deepening poverty or forgo healthcare services if a need arises. More is therefore required to provide financial protection to achieve universal health coverage in Ethiopia, where the informal sector is relatively large.