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

Out-of-pocket and indirect expenditure of spina bifida and hydrocephalus patients admitted for inpatient treatment and follow-up at two university-affiliated hospitals in Ethiopia

INTRODUCTION

In Ethiopia approximately 3,200,000 babies are born annually and 41.09 per 10,000 live births are affected by spina bifida. Hydrocephalus (HCP) is another common pediatric neurosurgical condition with studies in Ethiopia showing the most common etiology is post spina bifida closure. The out-of-pocket expense (OOPE) and indirect expense of patients treated surgically for spina bifida and hydrocephalus during the first year of life were assessed.

METHODS

A prospective hospital-based study was done on patients treated surgically for spina bifida and HCP in two university-affiliated hospitals, between April 1st, 2022, and April 1st, 2023. Data on direct and indirect expenses were collected during inpatient care and follow-up. Catastrophic health expenditure (CHE) was assessed, defined as total expenditure exceeding 10% of the total annual household expenditure.

RESULT

A total of 245 patients were eligible for analysis. The median annual total expenditure of households for treatment was ETB 11,510.00 with ETB 5700.00 being indirect expenditure. Forty-nine percent of the households suffered CHE. In multivariate analysis, the factors which were found to have a statistically significant association with CHE were the hospital where the patient received the treatment, the household's wealth quintile, the place of residency, and pre-admission duration of stay.

CONCLUSION

Our study revealed a high CHE in households with spina bifida and HCP. We recommend working on primary prevention of spina bifida, expanding surgical services regionally to minimize costs associated with travel for surgical care, and reducing pre-admission duration of stay by improving evaluation and investigations at outpatient clinics.

Missed nursing care and associated factors among nurses at University of Gondar Comprehensive Specialized Hospital, Ethiopia, 2022

The issue of missed nursing care is a problem that affects the overall quality of nursing care in hospitals around the world. However, there is limited research about it in Ethiopia. This study assessed missed nursing care and factors among nurses. An institutional-based cross-sectional study was conducted among 485 nurses at the University of Gondar Specialized Hospital. The data were collected from May 15 to June 15, 2022 using a self-administered questionnaire. A simple random sampling technique was used to select study participants. The data was entered to EPI DATA version 4.6 and exported to SPSS version 23 for analysis. Descriptive statistics were computed, and a summative score of missed nursing care was calculated. Then, multiple linear regression analysis was used to identify the factors. A P-value of 0.05 was used to declare significant level. In this study, missed nursing care was 62.5% (95% CI 60.98-64.02). Documentation, vital signs assessment, intravenous care, and assessment as per hospital policy and patient education were the most frequently missed nursing care. Being single in marital status (B = -4.609, P = 0.004), adequacy of nursing staff (B = -2.458, P = 0.003), satisfaction with income (B = -8.753, P = 0.007), working in medical unit (B = -5.708, P = 0.002) and working in both day and night shift (B = 1.731, P = 0.027) were statistically associated factors. More than half of the participants missed basic nursing care. Most of the identified factors correlated with missed nursing care negatively. Efforts should be done to enhance communication between health team members, assign a manageable number of patients per nurse, and adjust shifts and units.

Hidden cost of hospital-based delivery and associated factors among postpartum women attending public hospitals in Gamo zone, southern Ethiopia

BACKGROUND

Since 2005, the healthcare system in Ethiopia has implemented policies to promote the provision of free maternal healthcare services. The primary goal of these policies is to enhance the accessibility of maternity care for women from various socioeconomic backgrounds. Additionally, the aim is to increase the utilization of maternity services, such as institutional deliveries, by removing financial obstacles that pregnant women may face. Even though maternity services are free of charge. The hidden cost has unquestionably been a key obstacle in seeking and utilizing health care services. Significant payments due to delivery services could create a heavy economic burden on households.

OBJECTIVES

To determine the hidden cost of hospital-based delivery and associated factors among postpartum women attending public hospitals in Gamo zone, southern Ethiopia 2023.

METHODS

A facility-based cross-sectional study was conducted on 411 postpartum women in Gamo Zone Public Health Hospitals from December 1, 2022, to January 30, 2023. The systematic sampling technique was applied to reach study units. Data was collected using the Kobo Toolbox Data Collection Tool and exported to SPSS statistical software version 27 for analysis. Simple linear regression and multiple linear regression were done to see the association of variables. The significance level was declared at a P-value < 0.05 in the final model.

RESULT

The median hidden cost of hospital-based delivery was 1142 Ethiopian birr (ETB), with a range (Q) of 2262 (504-2766) ETB. Monthly income of the family (β = 0.019), obstetrics complications (β = 0.033), distance from the health facility (β = 0.003), and mode of delivery (β = 0.072), were positively associated with the hidden cost of hospital-based delivery. While, rural residence (β = -0.041) was negatively associated with the outcome variable.

CONCLUSION

This study showed the hidden cost of hospital based delivery was relatively high. Residence, monthly income of the family, obstetric complications, mode of delivery, and distance from the health facility were statistically significant. It is important to take these factors into account when designing health intervention programs and hospitals should prioritize the availability of essential drugs and medical supplies within their facilities to address direct medical costs in hospitals.

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.

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.

Work experience was associated with the knowledge and practice of catheter-associated urinary tract infection prevention among nurses at University of Gondar Comprehensive Specialized Hospital, northwest Ethiopia, 2021

BACKGROUND

Catheter-associated urinary tract infection is the source of about 20% of episodes of health-care acquired infections in acute care facilities and it is over 50% in long-term care facilities. In Ethiopia, there is no published scientific research regarding knowledge and practice of nurses on catheter-associated urinary tract infections prevention. Therefore, this study aimed to assess knowledge, practice and associated factors of CAUTI prevention among nurses working at university of Gondar comprehensive specialized hospital, northwest Ethiopia, 2021.

METHODS

Institutional based cross sectional study was conducted at University of Gondar Comprehensive Specialized Referral Hospital from April 01 to May 01, 2021 among 423 nurses. Simple random sampling technique was used. Data were collected by using self-administered questionnaire then coded and entered into EPI- Data version 4.6 and then exported to SPSS version 23. Descriptive statistics was computed, and the result was summarized by texts, tables, and charts. All variables with P-value < 0.25 in the univariate analysis were included in the multivariable regression analysis. The degree of association was interpreted by using the adjusted odds ratio with 95% confidence intervals.

RESULTS

Good knowledge and practice of nurses towards CAUTI prevention was 37.7% and 51.8% respectively. Good knowledge was associated with sex [AOR = 1.84, 95% CI (1.09, 3.11)], work experience [AOR = 2.36, 95% CI (1.09, 5.10)], working unit [AOR = 6.9, 95% CI (2.11, 22.52)], training [AOR = 2.33, 95% CI (1.17, 4.65)] and had guideline [AOR = 2.78, 95% CI (1.59, 4.88)]. Good practice was associated with sex, work experience, attitude and knowledge towards CAUTI prevention [AOR = 2.19, 95% CI (1.23, 3.88)], [AOR = 5.44, 95% CI (1.66, 17.84)], [AOR = 3.06, 95% CI (1.65, 5.67)], and [AOR = 5.28, 95% CI (2.86, 9.76)] respectively.

CONCLUSIONS

Nearly one-third of nurses had good knowledge and more than half of nurses had good practice towards CAUTI prevention. Sex, work experience, work unit, presence of guideline, and training were significantly associated with knowledge. Sex, work experience, good attitude and, knowledge were associated with practice of nurses towards CAUTI prevention. The knowledge and practice towards catheter associated urinary tract infection prevention among nurses should be increased, so that the patients could enjoy and maintain the healthy lifestyle.

Patient-related healthcare costs for diarrhoea, Guillain Barré syndrome and invasive non-typhoidal salmonellosis in Gondar, Ethiopia, 2020

Background

Globally, foodborne diseases result in a significant disease burden with low- and middle-income countries disproportionately affected. Estimates of healthcare costs related to foodborne disease can aid decision makers to take action to mitigate risks and prevent illness. However, only limited data on the African continent are available, especially related to more severe sequelae. We provide estimates of direct and indirect (non)-medical costs of patients with diarrhoea, Guillain-Barré syndrome (GBS), and invasive non-typhoidal salmonellosis (iNTS) in three healthcare facilities in Gondar, Ethiopia.

Methods

We used healthcare data from patient records, interviews with family caregivers and 2020 healthcare resource unit costs. Descriptive statistical analysis was performed. For diarrhoea, differences in mean and median transformed costs between healthcare facilities and etiologies (Campylobacter spp., enterotoxigenic Escherichia coli, non-typhoidal Salmonella enterica) were analysed with ANOVA and chi squared tests. Contribution of healthcare facility, dehydration severity, sex, age and living area to transformed costs was identified with linear regression. Results are in 2020 USD per patient. To extrapolate to national level, 2017 national incidence estimates were used.

Results

Mean direct medical costs were 8.96 USD for diarrhoea (health centre 6.50 USD, specialised hospital 9.53 USD, private clinic 10.56 USD), 267.70 USD for GBS, and 47.79 USD for iNTS. Differences in costs between diarrhoea patients were mainly associated with healthcare facility. Most costs did not differ between etiologies. Total costs of a diarrhoea patient in the specialised hospital were 67 USD, or 8% of gross national income per capita. For direct medical plus transport costs of a GBS and iNTS patient in the specialised hospital, this was 33% and 8%, respectively. Of the 83.9 million USD estimated national non-typhoidal Salmonella enterica related cost, 12.2% was due to iNTS, and of 187.8 million USD related to Campylobacter spp., 0.2% was due to GBS.

Conclusion

Direct medical costs per patient due to GBS and iNTS were 30 respectively five times those due to diarrhoea. Costs of a patient with diarrhoea, GBS or iNTS can be a substantial part of a household’s income. More severe sequalae can add substantially to cost-of-illness of foodborne hazards causing diarrheal disease.

Economic Costs of Providing District- and Regional-Level Surgeries in Tanzania

BACKGROUND

Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals.

METHODS

Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components.

RESULTS

The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants.

CONCLUSION

Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.

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 .

Healthcare Cost Reduction and Health Insurance Policy Improvement

OBJECTIVES

Reducing healthcare costs is a constant endeavor of all healthcare organizations, governments, policy makers, and individuals. A comparative study of available healthcare policies from the patient's perspective is not available. Furthermore, an analysis of how the various components of these policies affect the healthcare cost of a patient is required.

METHODS

Data were collected from 150 hospitalized patients in India regarding their views on 7 healthcare cost categories covering 22 cost components. These are statistically analyzed under 4 commonly used health insurance policies (2 government insurance schemes: ex-servicemen contributory health scheme and employee state insurance; private insurance schemes; and self-financing-ie, no insurance) to assess which healthcare cost component is more important under which policy option.

RESULTS

Under 7 healthcare cost categories, 22 cost components were studied, and out of these 22, 16 were found statistically significant. Results revealed that the treatment of all 16 significant cost components under the 4 health insurance policy options was statistically different.

CONCLUSIONS

Patients covered under government sector health insurance policies were found to be less concerned about healthcare costs, whereas those covered under private health insurance policies were found to be more cost-conscious. Access to healthcare or transportation costs to the healthcare facility is a key concern area for self-financed patients.

Effect of multimorbidity on utilisation and out-of-pocket expenditure in Indonesia: quantile regression analysis

BACKGROUND

Multimorbidity (the presence of two or more non-communicable diseases) is a major growing challenge for many low-income and middle-income countries (LMICs). Yet, its effects on health care costs and financial burden for patients have not been adequately studied. This study investigates the effect of multimorbidity across the different percentiles of healthcare utilisation and out-of-pocket expenditure (OOPE).

METHODS

We conducted a secondary data analysis of the 2014/2015 Indonesian Family Life Survey (IFLS-5), which included 13,798 respondents aged ≥40 years. Poisson regression was used to assess the association between sociodemographic characteristics and the total number of non-communicable diseases (NCDs), while multivariate logistic regression and quantile regression analysis was used to estimate the associations between multimorbidity, health service use and OOPE.

RESULTS

Overall, 20.8% of total participants had two or more NCDs in 2014/2015. The number of NCDs was associated with higher healthcare utilisation (coefficient 0.11, 95% CI 0.07-0.14 for outpatient care and coefficient 0.09 (95% CI 0.02-0.16 for inpatient care) and higher four-weekly OOPE (coefficient 27.0, 95% CI 11.4-42.7). The quantile regression results indicated that the marginal effect of having three or more NCDs on the absolute amount of four-weekly OOPE was smaller for the lower percentiles (at the 25th percentile, coefficient 1.0, 95% CI 0.5-1.5) but more pronounced for the higher percentile of out-of-pocket spending distribution (at the 90th percentile, coefficient 31.0, 95% CI 15.9-46.2).

CONCLUSION

Multimorbidity is positively correlated with health service utilisation and OOPE and has a significant effect, especially among those in the upper tail of the utilisation/costs distribution. Health financing strategies are urgently required to meet the needs of patients with multimorbidity, particularly for vulnerable groups that have a higher level of health care utilisation.

Risky sexual behavior and its associated factors among patients with severe mental disorder in University of Gondar Comprehensive Specialized Hospital, 2018

BACKGROUND

People with severe mental disorders are more likely to engage in high-risk sexual behaviors. As a result of these high-risk behaviors, they might contract sexually transmitted infections and become pregnant unintentionally. Despite the high burden of this problem, very little is known about the association between mental disorders and high-risk sexual behaviors; for this reason, the current study aimed at determining the association between these two behaviors in patients with mental disorders attending an outpatient clinic at the University of Gondar Comprehensive Specialized Hospital, Psychiatric Clinic.

METHODS

A total of 223 study participants were recruited via a stratified sampling followed by a systematic sampling technique. An institutional-based cross-sectional study was conducted from April to May 2018. Data were collected using a pretested interviewer-based questionnaire. A four-item questionnaire was adopted from a behavioral surveillance survey and different literature sources. A multivariable logistic regression model was fitted to assess the strength in addition to the direction of the association between risky sexual behavior and independent variables. An interpretation was made based on the adjusted odds ratio and p-value at a 95% confidence interval (CI).

RESULT

Nearly half of the study participants (49.8, 95% CI; 43.9-56.5%) presented risky sexual behavior. The study found that male gender (2.98; adjusted odds ration [AOR] = 2.98; 95% CI; 1.49-5.95), no ability to read and write (3.99; AOR = 3.99; 95% CI: 1.53-10.4), history of hospitalization (3.95; AOR = 3.95; 95% CI: 1.87-8.32), perceived internal stigma (2.45, AOR = 2.45; 95% CI: 1.18-5.11), and poor social support (3.07, AOR = 3.07; 95% CI: 1.29-7.30) were significant predictors of risky sexual behaviors among patients with severe mental disorder.

CONCLUSION

Risky sexual behavior among patients with a severe mental disorders was high (49.8%). Special attention should be given to male patients, incorporating people with severe mental disorders into the adult education programs, continuous health education regarding risky sexual behavior and utilization of condoms, building self-esteem, and engaging others to provide good social support systems are strongly recommended to alleviate this type of behavior in this population.

Economic impact of localized cutaneous leishmaniasis on adult patients of a referral service in Belo Horizonte, Minas Gerais State, Brazil

Cutaneous leishmaniasis (CL) is a disease associated with low-income populations. Thus, in assessing the burden of this disease, it is important to include its economic impact on individuals. We aimed to evaluate CL economic impact on patients treated at a referral service in the State of Minas Gerais, Brazil. This is a cross-sectional study based on the analysis of interviews and medical records from which we assembled direct medical and non-medical costs related to CL, from a societal perspective. One hundred patients were included; 50% had a monthly per capita income of up to USD 259.60 and spent on average USD 187.32 with the disease, representing an average monthly impact of 22.5% (USD 133.80). The disease imposed direct medical costs, such as: private medical appointments, medications, medical exams, dressing material, and co-participation in health insurances. Direct non-medical costs were mainly related to patients' transportation to health centers (USD 4,911.00), but also included medically-necessary care, food, and domestic and business outsourcing services. Although the Brazilian public health system guarantees access to health care, CL still represents a substantial economic impact for patients. The main action to reduce the expenses with this disease is decentralizing services for CL diagnosis and therapeutic approach, as well as increasing their efficiency.