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Ferreira MRL, Bonfim RO, Bossonario PA, Maurin VP, Valença ABM, Abreu PDD, Andrade RLDP, Fronteira I, Monroe AA. Social protection as a right of people affected by tuberculosis: a scoping review and conceptual framework. Infect Dis Poverty 2023; 12:103. [PMID: 37993962 PMCID: PMC10664497 DOI: 10.1186/s40249-023-01157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Tuberculosis is an infectious disease strongly influenced by social determinants closely associated with cycles of poverty and social exclusion. Within this context, providing social protection for people affected by the disease constitutes a powerful instrument for reducing inequalities and enhancing inclusion and social justice. This study aimed to identify and synthesize strategies and measures aimed at ensuring social protection as a right of people affected by tuberculosis. METHODS This is a scoping review, with searches conducted in six databases in February 2023. We included publications from 2015 onwards that elucidate strategies and measures of social protection aimed at safeguarding the rights to health, nutrition, employment, income, housing, social assistance, and social security for people affected by tuberculosis. These strategies could be implemented through policies, programs, and/or governmental agreements in any given context. The data extracted from the articles underwent descriptive analysis and a narrative synthesis of findings based on the dimensions of social protection. Additionally, we developed a conceptual framework illustrating the organizational and operational aspects of measures and strategies related to each dimension of social protection identified in this review. RESULTS A total of 9317 publications were retrieved from the databases, of which sixty-three publications were included. The study's results highlighted measures and strategies concerning the social protection of people affected by tuberculosis. These measures and strategies revolved around the rights to proper nutrition and nourishment, income, housing, and health insurance, as well as expanded rights encompassing social assistance and social welfare. It was reported that ensuring these rights contributes to improving nutritional status and the quality of life for individuals with tuberculosis, along with reducing catastrophic costs, expanding access to healthcare interventions and services, and fostering TB treatment adherence, thereby leading to higher rates of TB cure. CONCLUSIONS Our findings identify social protection measures as a right for people affected by tuberculosis and have the potential to guide the development of evidence-based social and health policies through collaboration between tuberculosis control programs and governmental entities.
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Affiliation(s)
| | - Rafaele Oliveira Bonfim
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
| | | | | | | | - Paula Daniella de Abreu
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
| | | | - Inês Fronteira
- Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, NOVA University Lisbon, Lisbon, Portugal
- National School of Public Health, Public Health Research Center, Comprehensive Health Research Center, NOVA University Lisbon, Lisbon, Portugal
| | - Aline Aparecida Monroe
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
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Li X, Mohanty I, Zhai T, Chai P, Niyonsenga T. Catastrophic health expenditure and its association with socioeconomic status in China: evidence from the 2011-2018 China Health and Retirement Longitudinal Study. Int J Equity Health 2023; 22:194. [PMID: 37735440 PMCID: PMC10515247 DOI: 10.1186/s12939-023-02008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND An increase in healthcare utilization in response to universal health coverage may leave massive economic burden on individuals and households. Identifying catastrophic health expenditure helps us understand such burden. This study aims to examine the incidence of catastrophic health expenditure at various thresholds, explore its trend over years, and investigate whether it varies across socioeconomic status (SES). METHODS Data used in this study were from four waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013, 2015, and 2018. SES was measured by annual per-capita household expenditure, which was then divided into quintiles (Quintile 1 (Q1): the poorest - Quintile 5 (Q5): the wealthiest). Catastrophic health expenditure was measured at both a fixed threshold (40%) and a set of variable thresholds, where the thresholds for other quintiles were estimated by multiplying 40% by the ratio of average food expenditure in certain quintile to that in the index quintile. Multilevel mixed-effects logistic regression models were used to analyze the determinants of catastrophic health expenditure at various thresholds. RESULTS A total of 6,953 households were included in our study. The incidence of catastrophic health expenditure varied across the thresholds set. At a fixed threshold, 10.90%, 9.46%, 13.23%, or 24.75% of households incurred catastrophic health expenditure in 2011, 2013, 2015, and 2018, respectively, which were generally lower than those at variable thresholds. Catastrophic health expenditure often decreased from 2011 to 2013, and an increasing trend occurred afterwards. Compared to households in Q5, those in lower quintiles were more likely to suffer catastrophic health expenditure, irrespective of the thresholds set. Similarly, having chronic diseases and healthcare utilization increased the odds of catastrophic health expenditure. CONCLUSIONS The financial protection against catastrophic health expenditure shocks remains a challenge in China, especially for the low-SES and those with chronic diseases. Concerted efforts are needed to further expand health insurance coverage across breadth, depth, and height, optimize health financing mechanism, redesign cost-sharing arrangements and provider payment methods, and develop more efficient expenditure control strategies.
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Affiliation(s)
- Xi Li
- Health Research Institute, Faculty of Health, University of Canberra, Building 23, 26 University Drive Street, Bruce, Canberra, 2617, Australia.
| | - Itismita Mohanty
- Health Research Institute, Faculty of Health, University of Canberra, Building 23, 26 University Drive Street, Bruce, Canberra, 2617, Australia
| | - Tiemin Zhai
- Department of Health Economics and National Health Accounts Research, China National Health Development Research Center, Beijing, China
| | - Peipei Chai
- Department of Health Economics and National Health Accounts Research, China National Health Development Research Center, Beijing, China
| | - Theo Niyonsenga
- Health Research Institute, Faculty of Health, University of Canberra, Building 23, 26 University Drive Street, Bruce, Canberra, 2617, Australia
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Ghazy RM, El Saeh HM, Abdulaziz S, Hammouda EA, Elzorkany AM, Khidr H, Zarif N, Elrewany E, Abd ElHafeez S. A systematic review and meta-analysis of the catastrophic costs incurred by tuberculosis patients. Sci Rep 2022; 12:558. [PMID: 35017604 PMCID: PMC8752613 DOI: 10.1038/s41598-021-04345-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
One of the strategies of the World Health Organization End Tuberculosis (TB) was to reduce the catastrophic costs incurred by TB-affected families to 0% by 2020.Catastrophic cost is defined by the total cost related to TB management exceeding 20% of the annual pre-TB household income. This study aimed to estimate the pooled proportion of TB affected households who incurred catastrophic costs. We searched PubMed, SciELO, Scopus, Embase, Google Scholar, ProQuest, SAGE, and Web of Science databases according to Preferred Reporting Items of the Systematic Reviews and Meta-Analysis (PRISMA) guidelines till November 20, 2020. Eligible studies were identified and data on catastrophic costs due to TB were extracted. We performed a meta-analysis to generate the pooled proportion of patients with TB facing catastrophic costs. From 5114 studies identified, 29 articles were included in the final analysis. The pooled proportion of patients faced catastrophic costs was (43%, 95% CI [34-51]). Meta-regression revealed that country, drug sensitivity, and Human immune-deficiency Virus (HIV) co-infection were the main predictors of such costs. Catastrophic costs incurred by drug sensitive, drug resistant, and HIV co-infection were 32%, 81%, and 81%, respectively. The catastrophic costs incurred were lower among active than passive case findings (12% vs. 30%). Half (50%) of TB-affected households faced catastrophic health expenditure at 10% cut-off point. The financial burden of patients seeking TB diagnosis and treatment continues to be a worldwide impediment. Therefore, the End TB approach should rely on socioeconomic support and cost-cutting initiatives.PROSPERO registration: CRD42020221283.
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Affiliation(s)
- Ramy Mohamed Ghazy
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Haider M El Saeh
- Community Medicine Department, Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | | | | | | | - Heba Khidr
- Ministry of Health and Population, Alexandria, Egypt
| | - Nardine Zarif
- Ministry of Health and Population, Alexandria, Egypt
| | - Ehab Elrewany
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Samar Abd ElHafeez
- Epidemiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
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Sun CY, Shi JF, Fu WQ, Zhang X, Liu GX, Chen WQ, He J. Catastrophic Health Expenditure and Its Determinants Among Households With Breast Cancer Patients in China: A Multicentre, Cross-Sectional Survey. Front Public Health 2021; 9:704700. [PMID: 34291034 PMCID: PMC8287064 DOI: 10.3389/fpubh.2021.704700] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/08/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Although numerous studies have examined catastrophic health expenditures (CHE) worldwide, most focus on the general population, not on specific vulnerable groups. We aimed to analyse the extent and the influencing factors of CHE in households with breast cancer patients in China, and explore the ability of different insurances to protect these households from CHE. Methods: A multicentre, cross-sectional interview surveys was conducted in households with breast cancer patients across seven provinces/municipalities in China. CHE were defined as out-of-pocket expenditures ≥ 40% of households' non-food expenditures. Chi-square tests and logistic regression analysis were performed to identify the determinants of CHE in household with breast cancer patients. Results: In the 639 participating households with breast cancer patients, the mean out-of-pocket (OOP) expenditure accounted for ~55.20% of the mean households' non-food expenditures. The overall incidence of CHE was 87.95 and 66.28% before and after insurance compensation, respectively. The logistic regression model revealed that education, disease course, health insurance, treatment method, and income were significant predictors of CHE. Conclusions: The results indicated that medical insurance protects some households with breast cancer patients from the impact of CHE. However, their reimbursement rates were relatively low. Therefore, breast cancer still had a significant catastrophic effect on the economy of households. Policy efforts should focus on improving insurance compensation rates and relieving the economic burden of critical illnesses such as breast cancer.
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Affiliation(s)
- Cheng-Yao Sun
- Department of Health Economics, College of Health Management of Harbin Medical University, Harbin, China
| | - Ju-Fang Shi
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Qi Fu
- Department of Health Economics, College of Health Management of Harbin Medical University, Harbin, China
| | - Xin Zhang
- Department of Health Economics, College of Health Management of Harbin Medical University, Harbin, China
| | - Guo-Xiang Liu
- Department of Health Economics, College of Health Management of Harbin Medical University, Harbin, China
| | - Wan-Qing Chen
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie He
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Watson J, Yazbeck AS, Hartel L. Making Health Insurance Pro-poor: Lessons from 20 Developing Countries. Health Syst Reform 2021; 7:e1917092. [PMID: 34402399 DOI: 10.1080/23288604.2021.1917092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The last 20 years have seen a substantial growth in research on the extent to which health sector reforms are pro-poor or pro-rich. What has been missing is knowledge synthesis work to derive operational lessons from the empirical research. This article fills the gap for the most popular form of health financing reform, health insurance. Based on publications covering 20 developing countries, we find that health insurance is no panacea for improving equity in the health sector. More importantly, we find certain design elements of health insurance can increase the likelihood of tackling inequality in the health sector in developing countries.
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Affiliation(s)
- Julia Watson
- International Development Division, Abt Associates Inc, Rockville, Maryland, USA
| | - Abdo S Yazbeck
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lauren Hartel
- International Development Division, Abt Associates Inc, Rockville, Maryland, USA
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Ghazy RM, Saeh HME, Abdulaziz S, Hammouda EA, Elzorkany A, Kheder H, Zarif N, Elrewany E, Elhafeez SA. A Systematic Review and Meta-Analysis on Catastrophic Cost incurred by Tuberculosis Patients and their Households.. [DOI: 10.1101/2021.02.27.21252453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
AbstractBackgroundAs one of the World Health Organization (WHO) End Tuberculosis (TB) Strategy is to reduce the proportion of TB affected families that face catastrophic costs to 0% by 2020. This systematic review and meta-analysis aimed to estimate the pooled proportion of TB affected households who face catastrophic cost.MethodA search of the online database through September 2020 was performed. A total of 5114 articles were found, of which 29 articles got included in quantitative synthesis. Catastrophic cost is defined if total cost related to TB exceeded 20% of annual pre-TB household income. R software was used to estimate the pooled proportion at 95% confidence intervals (CIs) using the fixed/random-effect models.ResultThe proportion of patients faced catastrophic cost was 43% (95% CI 34-52, I2= 99%); 32% (95% CI 29 – 35, I2= 70%) among drug sensitive, and 80% (95% CI 74-85, I2= 54%) among drug resistant, and 81% (95%CI 78-84%, I2= 0%) among HIV patients. Regarding active versus passive case finding the pooled proportion of catastrophic cost was 12% (95% CI 9-16, I2= 95%) versus 42% (95% CI 35-50, I2= 94%). The pooled proportion of direct cost to the total cost was 45% (95% CI 39-51, I2= 91%). The pooled proportion of patients facing catastrophic health expenditure (CHE) at cut of point of 10% of their yearly income was 45% (95% CI 35-56, I2= 93%) while at 40% of their capacity to pay was 63% (95% CI 40-80, I2= 96%).ConclusionDespite the ongoing efforts, there is a significant proportion of patients facing catastrophic cost, which represent a main obstacle against TB control.PROSPERO registrationCRD42020221283
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Liu J, Han Z, Veuthey J, Ma B. How investment in public health has impacted the prevalence of tuberculosis in China: A study of provincial variations between 2005 and 2015. Int J Health Plann Manage 2020; 35:1546-1558. [PMID: 32978844 PMCID: PMC7756655 DOI: 10.1002/hpm.3034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/12/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022] Open
Abstract
How do public investments in public health actually impact health outcomes? This question has not been investigated enough, especially regarding infectious diseases. This study investigates the correlations between public health expenditure and the incidence of tuberculosis in China using a provincial panel dataset. The analysis focuses on the correlations between public health expenditure and tuberculosis incidence, using the fixed effects models and Two Stage Least Squares (2SLS) method. Overall, a 10% increase of public health expenditure per capita is associated with a 0.0019% decrease of tuberculosis incidence. A series of robustness tests show that the correlation between public health expenditure and TB incidence is valid. Future research should focus more on the performance of public health, particularly infectious diseases like tuberculosis, and provide references for health policymakers.
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Affiliation(s)
- Jie Liu
- School of Political Science and Public Administration, Shandong University, Qingdao, China
| | - Ziqiang Han
- School of Political Science and Public Administration, Shandong University, Qingdao, China
| | - Justin Veuthey
- School of Political Science and Public Administration, Shandong University, Qingdao, China.,School of Humanitarian Studies, Royal Roads University, Victoria, Canada
| | - Ben Ma
- School of Political Science and Public Administration, Shandong University, Qingdao, China
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8
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Wang H, Dong R. A touching letter vs a terrible tragedy:What we learned. Int J Clin Pract 2020; 74:e13514. [PMID: 32306472 DOI: 10.1111/ijcp.13514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 04/13/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hong Wang
- Department of Pediatrics, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, People's Republic of China
| | - Rui Dong
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao University, Qingdao, People's Republic of China
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Li H, Cheng B, Chen Y. What causes high costs for rural tuberculosis inpatients? Evidence from five counties in China. BMC Infect Dis 2020; 20:501. [PMID: 32652944 PMCID: PMC7353759 DOI: 10.1186/s12879-020-05235-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 07/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background Tuberculosis (TB) still causes high economic burden on patients in China, especially for rural patients. Our study aims to explore the risk factors associated with the high costs for TB inpatients in rural China from the aspects of inpatients’ socio-demographic and institutional attributes. Methods Generalized linear models were utilized to investigate the factors associated with TB inpatients’ total costs and out-of-pocket (OOP) expenditures. Quantile regression (QR) models were applied to explore the effect of each factor across the different costs range and identify the risk factors of high costs. Results TB inpatients with long length of stay and who receive hospitalization services cross provincially, in tertiary and specialized hospitals were likely to face high total costs and OOP expenditures. QR models showed that high total costs occurred in Dingyuan and Funan Counties, but they were not accompanied by high OOP expenditures. Conclusions Early diagnosis, standard treatment and control of drug-resistant TB are still awaiting for more efforts from the government. TB inpatients should obtain medical services from appropriate hospitals. The diagnosis and treatment process of TB should be standardized across all designated medical institutions. Furthermore, the reimbursement policy for migrant workers who suffered from TB should be ameliorated.
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Affiliation(s)
- Haomiao Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China.,Institute of Model Animals of Wuhan University, Wuhan, 430072, China.,Research center for Rural Health Services, Hubei Province Key Research Institute of Humanities and Social Sciences, Wuhan, 430030, Hubei, China
| | - Bin Cheng
- China National Health Development Research Center, Beijing, 100044, China
| | - Yingchun Chen
- Research center for Rural Health Services, Hubei Province Key Research Institute of Humanities and Social Sciences, Wuhan, 430030, Hubei, China. .,School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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Zhao SW, Zhang XY, Dai W, Ding YX, Chen JY, Fang PQ. Effect of the catastrophic medical insurance on household catastrophic health expenditure: evidence from China. GACETA SANITARIA 2020; 34:370-376. [DOI: 10.1016/j.gaceta.2018.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 10/03/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022]
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Assebe LF, Negussie EK, Jbaily A, Tolla MTT, Johansson KA. Financial burden of HIV and TB among patients in Ethiopia: a cross-sectional survey. BMJ Open 2020; 10:e036892. [PMID: 32487582 PMCID: PMC7265036 DOI: 10.1136/bmjopen-2020-036892] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES HIV and tuberculosis (TB) are major global health threats and can result in household financial hardships. Here, we aim to estimate the household economic burden and the incidence of catastrophic health expenditures (CHE) incurred by HIV and TB care across income quintiles in Ethiopia. DESIGN A cross-sectional survey. SETTING 27 health facilities in Afar and Oromia regions for TB, and nationwide household survey for HIV. PARTICIPANTS A total of 1006 and 787 individuals seeking HIV and TB care were enrolled, respectively. OUTCOME MEASURES The economic burden (ie, direct and indirect cost) of HIV and TB care was estimated. In addition, the CHE incidence and intensity were determined using direct costs exceeding 10% of the household income threshold. RESULTS The mean (SD) age of HIV and TB patient was 40 (10), and 30 (14) years, respectively. The mean (SD) patient cost of HIV was $78 ($170) per year and $115 ($118) per TB episode. Out of the total cost, the direct cost of HIV and TB constituted 69% and 46%, respectively. The mean (SD) indirect cost was $24 ($66) per year for HIV and $63 ($83) per TB episode. The incidence of CHE for HIV was 20%; ranges from 43% in the poorest to 4% in the richest income quintile (p<0.001). Similarly, for TB, the CHE incidence was 40% and ranged between 58% and 20% among the poorest and richest income quintiles, respectively (p<0.001). This figure was higher for drug-resistant TB (62%). CONCLUSIONS HIV and TB are causes of substantial economic burden and CHE, inequitably, affecting those in the poorest income quintile. Broadening the health policies to encompass interventions that reduce the high cost of HIV and TB care, particularly for the poor, is urgently needed.
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Affiliation(s)
- Lelisa Fekadu Assebe
- Department Of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
- Disease Prevention and Control, Ministry of Health, Addis Ababa, Ethiopia
| | | | - Abdulrahman Jbaily
- Department Of Global Health and Population, Harvard T.H.Chan School of Public Health,Harvard University, Boston, Massachusetts, USA
| | - Mieraf Taddesse Taddesse Tolla
- Department Of Global Health and Population, Harvard T.H.Chan School of Public Health,Harvard University, Boston, Massachusetts, USA
| | - Kjell Arne Johansson
- Department Of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
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Ogbuabor DC. Through service providers' eyes: health systems factors affecting implementation of tuberculosis control in Enugu State, South-Eastern Nigeria. BMC Infect Dis 2020; 20:206. [PMID: 32143584 PMCID: PMC7060534 DOI: 10.1186/s12879-020-4944-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/02/2020] [Indexed: 01/06/2023] Open
Abstract
Background Well-functioning health systems are essential to achieving global and national tuberculosis (TB) control targets. This study examined health system factors affecting implementation of TB control programme from the perspectives of service providers. Methods The study was conducted in Enugu State, South-eastern Nigeria using qualitative, cross-sectional design involving 23 TB service providers (13 district TB supervisors and 10 facility TB focal persons). Data were collected through in-depth, semi-structured interviews using a health system dynamic framework and analysed thematically. Results Stewardship from National TB Control Programme (NTP) improved governance of TB control, but stewardship from local government was weak. Government spending on TB control was inadequate, whereas donors fund TB control. Poor human resources management practices hindered TB service delivery. TB service providers have poor capacity for data management because changes in recording and reporting tools were not matched with training of service providers. Drugs and other supplies to TB treatment centres were interrupted despite the use of a logistics agency. Poor integration of TB into general health services, weak laboratory capacity, withdrawal of subsidies to community volunteers and patent medicine vendors, poorly funded patient tracking systems, and ineffectual TB/HIV collaboration resulted in weak organisation of TB service delivery. Conclusion Health systems strengthening for TB control service must focus on effective oversight from NTP and local health system; predictable domestic resource mobilisation through budgets and social health insurance; training and incentives to attract and retain TB service providers; effective supply and TB drug management; and improvements in organization of service delivery.
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Affiliation(s)
- Daniel Chukwuemeka Ogbuabor
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria. .,Department of Health Systems and Policy, Sustainable Impact Resource Agency, Enugu, Enugu State, Nigeria.
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Sun J, Lyu S. The effect of medical insurance on catastrophic health expenditure: evidence from China. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:10. [PMID: 32127784 PMCID: PMC7045636 DOI: 10.1186/s12962-020-00206-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 02/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background The Chinese government has established a nationwide multiple-level medical insurance system. However, catastrophic health expenditure (CHE) causes great harm to the quality of life of households and pushes them into poverty. The objective of this paper is to assess the effect of medical insurance on CHE in China and compare the financial protection effects of different medical insurances. Methods Panel data were obtained from China Family Panel Studies (CFPS) conducted in the years of 2012, 2014, and 2016. CHE incidence was measured by performing a headcount, and its intensity was estimated using overshoot and mean positive overshoot (MPO). In addition, concentration index (CI) was used to measure the degree of socioeconomic inequality of CHE occurrence. Furthermore, random effects panel Probit regression model was employed to assess the effect of medical insurance on CHE. Lastly, random effects panel Logit regression model was adopted to perform a robustness check. Results From 2012 to 2016, the total CHE incidence jumped from 15.05% to 15.24%, and the CI in CHE changed from − 0.0076 to − 0.1512. Moreover, the total overshoot increased from 0.0333 to 0.0344, while the total MPO grew from 0.2213 to 0.2257. Furthermore, the global regression results show that residents covered by Supplementary Medical Insurance (SMI) were linked to a decreased probability of experiencing CHE. In addition, the regression results by gender indicate that SMI coverage for male residents had a significant effect on the prevention of CHE, while the effect was not significant for female residents. The regression results by health status show that SMI had a significant impact on reducing the likelihood of CHE occurrence for healthy residents, whilst the impact was not significant for unhealthy residents. Lastly, the robustness check results were consistent with those of previous findings. Conclusion The results of this study suggest that CHE incidence and intensity became relatively higher among households. In addition, CHE occurrence was concentrated among the poorer households and the equality status worsened. Moreover, financial protection effects of the four medical insurance schemes against CHE varied significantly. Furthermore, the protection effect of SMI against CHE shows significant gender and health status disparities.
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Affiliation(s)
- Jian Sun
- 1School of International and Public Affairs, Shanghai Jiao Tong University, No. 1954 Huashan Road, Xuhui District, Shanghai, 200030 China
| | - Shoujun Lyu
- 1School of International and Public Affairs, Shanghai Jiao Tong University, No. 1954 Huashan Road, Xuhui District, Shanghai, 200030 China.,2China Institute for Urban Governance, Shanghai Jiao Tong University, No. 1954 Huashan Road, Xuhui District, Shanghai, 200030 China
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Liu Y, Xu CH, Wang XM, Wang ZY, Wang YH, Zhang H, Wang L. Out-of-pocket payments and economic consequences from tuberculosis care in eastern China: income inequality. Infect Dis Poverty 2020; 9:14. [PMID: 32019611 PMCID: PMC7001258 DOI: 10.1186/s40249-020-0623-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the availability of free tuberculosis (TB) diagnosis and treatment, TB care still generates substantial costs that push people into poverty. We investigated out-of-pocket (OOP) payments for TB care and assessed the resulting economic burden and economic consequences for those with varying levels of household income in eastern China. METHODS A cross-sectional study was conducted among TB patients in the national TB programme networks in eastern China. TB-related direct OOP costs, time loss, and coping strategies were investigated across households in different economic strata. Analysis of Variance was used to examine the differences in various costs, and Kruskal-Wallis tests were used to compare the difference in total costs as a percentage of annual household income. RESULTS Among 435 patients, the mean OOP total costs of TB care were USD 2389.5. In the lower-income quartile, OOP payments were lower, but costs as a percentage of reported annual household income were higher. Medical costs and costs prior to treatment accounted for 66.4 and 48.9% of the total costs, respectively. The lower the household income was, the higher the proportion of medical costs to total costs before TB treatment, but the lower the proportion of medical costs patients spent in the intensive phase. TB care caused 25.8% of TB-affected households to fall below the poverty line and caused the poverty gap (PG) to increase by United States Dollar (USD) 145.6. Patients in the poorest households had the highest poverty headcount ratio (70.2%) and PG (USD 236.1), but those in moderately poor households had the largest increase in the poverty headcount ratio (36.2%) and PG (USD 177.8) due to TB care. Patients from poor households were more likely to borrow money to cope with the costs of TB care; however, there were fewer social consequences, except for food insecurity, in poor households. CONCLUSIONS Medical and pretreatment costs lead to high costs of TB care, especially among patients from the poorest households. It is necessary to train health system staff in general hospitals to promptly identify and refer TB patients. Pro-poor programmes are also needed to protect TB patients from the medical poverty trap.
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Affiliation(s)
- Yan Liu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China.,Department of Critical Care Medicine, The Second People's Hospital of Shenzhen & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, 518035, China
| | - Cai-Hong Xu
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control, Beijing, 100226, China
| | - Xiao-Mo Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Zhen-Yu Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Yan-Hong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control, Beijing, 100226, China.
| | - Li Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China.
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15
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JOSHANI KHEIBARI M, ESMAEILI R, KAZEMIAN M. Impacts of Health Reform Plan in Iran on Health Payments Distributions and Catastrophic Expenditure. IRANIAN JOURNAL OF PUBLIC HEALTH 2019; 48:1861-1869. [PMID: 31850264 PMCID: PMC6908924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Health reform in Iran began in 2014, aimed at improving financing pattern of health services. We assessed the reform by changes in variables representing distribution of health payments and catastrophic expenditures. METHODS Using data from households' income-expenditure survey, this study computed the financial variables, representing poverty line and households at poor state, household's catastrophic health expenditure, fairness in financial contribution (FFC) index, and household's impoverishment state, in the years 2010-2016, in urban and rural areas. The variables were computed by special software designed for this study, based on C-Sharp(C#) programming language, with yearly data on more than 38000 households, each with 1072 information sources. RESULTS The food share-based poverty line after sharp rise in 2010-2013, in 2014-2016 raised slowly, and the average percent of households facing catastrophic health expenditure, after sharp rise in 2011-2013, left at 3.25 in 2014-2015 and raised to 3.45 in 2016. The average FFC index remained at 0.839 to 0.837 in 2013-2016. However, interestingly, the average percent of households impoverished after out-of-pocket payments improved from 1.36 to 0.912 in 2013-2016. CONCLUSION In three years of health reform, the major impact of reform was considerable improvements in the rate of the impoverished after out-of-pocket payments. The reform had limited impacts on the rates of households facing catastrophic health expenditure, and on FFC indexes, for the rural and urban residents.
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Affiliation(s)
- Morteza JOSHANI KHEIBARI
- Social Determinants of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Reza ESMAEILI
- Department of Public Health, School of Health, Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Mahmood KAZEMIAN
- Department of Health Economics, School of Medicine, Shahed University, Tehran, Iran,Corresponding Author:
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Mao W, Jiang W, Hamilton C, Zhang H, Huang F, Lucas H, Huan S, Tang S. Over- and under-treatment of TB patients in Eastern China: an analysis based on health insurance claims data. Trop Med Int Health 2019; 24:1078-1087. [PMID: 31299130 PMCID: PMC6851836 DOI: 10.1111/tmi.13287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective Poor compliance with existing guidelines for tuberculosis (TB) care and treatment is an issue of concern in China. We assessed health service use by TB patients over the entire treatment process and compared it to the recommended guidelines. Methods We collected insurance claims data in three counties of one province of Eastern China. Patient records with a diagnosis of ‘pulmonary TB’ in 2015 and 2016 were extracted. Treatment duration, number of outpatient (OP) visits and hospital admissions, as well as total cost, out‐of‐pocket (OOP) payments and effective reimbursement rates were analysed. Results A total of 1394 patients were included in the analysis. More than 48% received over the 8 months of treatment that TB guidelines recommend, and over 28% received less. 49% of Urban and Rural Resident Basic Medical Insurance (URRBMI) TB patients were hospitalised while 30% of those with Urban Employee Basic Medical Insurance (UEBMI) had at least one admission. Median total cost for patients with hospital admission was almost 10 times that of patients without. By comparison, the average OOP was 5 times higher. UEBMI patients had a shorter treatment period, more outpatient visits but considerably fewer hospital admissions than URRBMI patients. Conclusions We found an alarming extent of TB over‐ and under‐treatment in our study population. There is an urgent need to improve compliance with treatment guidelines in China and to better understand the drivers of divergence. Extending the coverage of health insurance schemes and increasing reimbursement rates for TB outpatient services would seem to be key factors in reducing both the overall cost and financial burden on patients.
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Affiliation(s)
- Wenhui Mao
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Weixi Jiang
- Global Health Research Center, Duke Kunshan University, Kunshan, China
| | | | - Hui Zhang
- National Center for TB Control and Prevention, China CDC, Beijing, China
| | - Fei Huang
- National Center for TB Control and Prevention, China CDC, Beijing, China
| | - Henry Lucas
- Institute of Development Studies, Sussex University, Brighton, UK
| | | | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Global Health Research Center, Duke Kunshan University, Kunshan, China
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Xu CH, Jeyashree K, Shewade HD, Xia YY, Wang LX, Liu Y, Zhang H, Wang L. Inequity in catastrophic costs among tuberculosis-affected households in China. Infect Dis Poverty 2019; 8:46. [PMID: 31215476 PMCID: PMC6582572 DOI: 10.1186/s40249-019-0564-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are limited nationally representative studies globally in the post-2015 END tuberculosis (TB) era regarding wealth related inequity in the distribution of catastrophic costs due to TB care. Under the Chinese national tuberculosis programme setting, we aimed to assess extent of equity in distribution of total TB care costs (pre-treatment, treatment and overall) and costs as a proportion of annual household income (AHI), and describe and compare equity in distribution of catastrophic costs (pre-treatment, treatment and overall) across population sub-groups. METHODS Analytical cross-sectional study using data from national TB patient cost survey carried out in 22 counties from six provinces in China in 2017. Drug-susceptible pulmonary TB registered under programme, who had received at least 2 weeks of intensive phase therapy were included. Equity was depicted using concentration curves and concentration indices were compared using dominance test. RESULTS Of 1147 patients, the median cost of pre-treatment, treatment and overall care, were USD 283.5, USD 413.1 and USD 965.5, respectively. Richer quintiles incurred significantly higher pre-treatment and treatment costs compared to poorer quintiles. The distribution of costs as a proportion of AHI and catastrophic costs were significantly pro-poor overall as well as during pre-treatment and treatment phase. All the concentration curves for catastrophic costs (due to pre-treatment, treatment and overall care) stratified by region (east, middle and west), area of residence (urban, rural) and type of insurance (new rural co-operative medical system [NCMS], non-NCMS) also exhibited a pro-poor pattern with statistically significant (P < 0.01) concentration indices. The pro-poor distribution of the catastrophic costs due to TB treatment was significantly more inequitable among rural, compared to urban patients, and NCMS compared to non-NCMS beneficiaries. CONCLUSIONS There is inequity in the distribution of catastrophic costs due to TB care. Universal health coverage, social protection strategies complemented by quality TB care is vital to reduce inequitable distribution of catastrophic costs due to TB care in China.
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Affiliation(s)
- Cai-Hong Xu
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Kathiresan Jeyashree
- Velammal Medical College Hospital and Research Institute, Madurai, 625009, India
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, 110016, India
- International Union Against Tuberculosis and Lung Disease (The Union), 75006, Paris, France
- Karuna Trust, Bengaluru, 560041, India
| | - Yin-Yin Xia
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Li-Xia Wang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Yan Liu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China.
| | - Li Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China.
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Ogbuabor DC, Onwujekwe OE. Governance of tuberculosis control programme in Nigeria. Infect Dis Poverty 2019; 8:45. [PMID: 31203814 PMCID: PMC6572737 DOI: 10.1186/s40249-019-0556-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/28/2019] [Indexed: 12/01/2022] Open
Abstract
Background The role of governance in strengthening tuberculosis (TB) control has received little research attention. This review provides evidence of how institutional designs and organisational practices influence implementation of the national TB control programme (NTP) in Nigeria. Main text We conducted a scoping review using a five-stage framework to review published and grey literature in English, on implementation of Nigeria’s NTP and identified themes related to governance using a health system governance framework. We included articles, of all study designs and methods, which described or analysed the processes of implementing TB control based on relevance to the research question. The review shows a dearth of studies which examined the role of governance in TB control in Nigeria. Although costed plans and policy coordination framework exist, public spending on TB control is low. While stakeholders’ involvement in TB control is increasing, institutional capacity is limited, especially in the private sector. TB-specific legislation is absent. Deployment and transfer of staff to the NTP are not transparent. Health workers are not transparent in communicating service entitlements to users. Despite existence of supportive policies, integration of TB control into the community and general health services have been weak. Willingness to pay for TB services is high, however, transaction cost and stigma among patients limit equity. Effectiveness and efficiency of the NTP was hindered by inadequate human resources, dilapidated service delivery infrastructure and weak drug supply system. Despite adhering to standardized recording and reporting format, regular monitoring and evaluation, revision of reporting formats, and electronic data management system, TB surveillance system was found to be weak. Delay in TB diagnosis and initiation of care, poor staff attitude to patients, lack of privacy, poor management of drug reactions and absence of infection control measures breach ethical standards for TB care. Conclusions This scoping review of governance of TB control in Nigeria highlights two main issues. Governance for strengthening TB control programmes in low-resource, high TB burden settings like Nigeria, is imperative. Secondly, there is a need for empirical studies involving detailed analysis of different dimensions of governance of TB control. Electronic supplementary material The online version of this article (10.1186/s40249-019-0556-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Chukwuemeka Ogbuabor
- Department of Health Systems and Policy, Sustainable Impact Resource Agency, University of Nigeria Enugu Campus (UNEC), 22 Ogidi Street, Asata, Enugu, P.O. Box 15534, Enugu, Enugu State, Nigeria. .,Department of Health Administration and Management, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria.
| | - Obinna Emmanuel Onwujekwe
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria.,Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria
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19
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Si Y, Zhou Z, Su M, Wang X, Lan X, Wang D, Gong S, Xiao X, Shen C, Ren Y, Zhao D, Hong Z, Bian Y, Chen X. Decomposing inequality in catastrophic health expenditure for self-reported hypertension household in Urban Shaanxi, China from 2008 to 2013: two waves' cross-sectional study. BMJ Open 2019; 9:e023033. [PMID: 31076467 PMCID: PMC6528006 DOI: 10.1136/bmjopen-2018-023033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Despite the latest wave of China's healthcare reform initiated in 2009 has achieved unprecedented progress in rural areas, little is known for specific vulnerable groups' catastrophic health expenditure (CHE) in urban China. This study aims to estimate the trend of incidence, intensity and inequality of CHE in hypertension households (households with one or more than one hypertension patient) in urban Shaanxi, China from 2008 to 2013. METHODS Based on the fourth and the fifth National Health Service Surveys of Shaanxi, we identified 460 and 1289 households with hypertension in 2008 and 2013, respectively for our analysis. We classified hypertension households into two groups: simplex households (with hypertension only) and mixed households (with hypertension plus other non-communicable diseases). CHE would be identified if out-of-pocket healthcare expenditure was equal to or higher than 40% of a household's capacity to pay. Concentration index and its decomposition based on Probit regressions were employed to measure the income-related inequality of CHE. RESULTS We find that CHE occurred in 11.2% of the simplex households and 22.1% of the mixed households in 2008, and the 21.5% of the simplex households and the 46.9% of mixed households incurred CHE in 2013. Furthermore, there were strong pro-poor inequalities in CHE in the simplex households (-0.279 and -0.283) and mixed households (-0.362 and -0.262) both in 2008 and 2013. The majority of observed inequalities in CHE could be associated with household economic status, household head's health status and having elderly members. CONCLUSION We find a sharp increase of CHE occurrence and the sustained strong pro-poor inequalities for simplex and mixed households in urban Shaanxi Province of China from 2008 to 2013. Our study suggests that more concerns are needed for the vulnerable groups such as hypertension households in urban areas of China.
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Affiliation(s)
- Yafei Si
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
- Global Health Institute, Xi’an Jiaotong University, Xi’an, China
| | | | - Xiao Wang
- International Business School, Xi’an Jiaotong-Liverpool University, Suzhou, China
| | - Xin Lan
- School of Public Health, Xi’an Jiaotong University School of Medicine, Xi’an, Shaanxi, China
| | - Dan Wang
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Shaoqing Gong
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Xiao Xiao
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Chi Shen
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Yangling Ren
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Dantong Zhao
- School of Public Health, Xi’an Jiaotong University School of Medicine, Xi’an, Shaanxi, China
| | - Zihan Hong
- International Business School, Xi’an Jiaotong-Liverpool University, Suzhou, China
| | - Ying Bian
- Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
| | - Xi Chen
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Department of Economics, Yale University, New Haven, CT, USA
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Jiang J, Chen S, Xin Y, Wang X, Zeng L, Zhong Z, Xiang L. Does the critical illness insurance reduce patients' financial burden and benefit the poor more: a comprehensive evaluation in rural area of China. J Med Econ 2019; 22:455-463. [PMID: 30744446 DOI: 10.1080/13696998.2019.1581620] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Critical illness insurance (CII) is one kind of health insurance that is gradually gaining attention worldwide. China implemented CII in 2012 to decrease patients' out-of-pocket (OOP) medical payments. The aims of this study were to determine if the project had positive impacts on relieving financial burden and improving health equity. METHODS A series of questionnaire surveys were undertaken in two counties before and after the intervention in rural China. OOP expenditure, catastrophic Health Expenditure (CHE) incidence, and associated average gap (AG) were assessed across different income groups and project durations, measuring short-term direct medical cost. Medical debt rate and amount were used to measure long-term financial burden; concentration index (CI) was calculated for equity. All data were evaluated by descriptive statistics and multi-variate variance analysis. The linear regression and logit regression with random effect analysis upon area was used to evaluate the effect of CII. RESULTS Six hundred and thirteen and 834 patients were surveyed at baseline and final evaluation. After the program, the OOP payments of hospitalizations sharply decreased from RMB 39,363.2 to RMB 28,426.1 (p < 0.001), with the largest decrease for lowest income patients (from RMB 44,507.6 to RMB 29,214.2). With longer duration of CII, more OOP medical payments decreased. The amount of medical debt was decreased by RMB 7,209.4 among all the patients, and the decrease was highest in the highest income group (RMB 8,119.9). The CI of AG changed a lot (from -0.858 to -0.670). CONCLUSION The CII has effectively reduced the financial burden of patients with high medical cost, whether in the short-term or a longer length of time. It also improved health equity in health service utilization and expenditure. However, rich householders still receive more benefits from the policy, government health insurance financing is increased, and the policy needs to further benefit the poor.
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Affiliation(s)
- Junnan Jiang
- a School of Medicine and Health Management , Huazhong University of Science and Technology , Wuhan , China
| | - Shanquan Chen
- b Jockey Club School of Public Health and Primary Care , Chinese University of Hong Kong , Hong Kong , China
| | - Yanjiao Xin
- a School of Medicine and Health Management , Huazhong University of Science and Technology , Wuhan , China
| | - Xuefeng Wang
- a School of Medicine and Health Management , Huazhong University of Science and Technology , Wuhan , China
| | - Li Zeng
- a School of Medicine and Health Management , Huazhong University of Science and Technology , Wuhan , China
| | - Zhengdong Zhong
- a School of Medicine and Health Management , Huazhong University of Science and Technology , Wuhan , China
| | - Li Xiang
- a School of Medicine and Health Management , Huazhong University of Science and Technology , Wuhan , China
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New Health Care Reform and Impoverishment among Chronic Households in China: A Random-Intercept Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16061074. [PMID: 30917496 PMCID: PMC6466394 DOI: 10.3390/ijerph16061074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/18/2019] [Accepted: 03/21/2019] [Indexed: 11/28/2022]
Abstract
High out-of-pocket (OOP) payments for chronic disease care often contribute directly to household poverty. Although previous studies have explored the determinants of impoverishment in China, few published studies have compared levels of impoverishment before and after the New Health Care Reform (NHCR) in households with members with chronic diseases (hereafter referred to as chronic households). Our study explored this using data from the fourth and fifth National Health Service Surveys conducted in Shaanxi Province. In total, 1938 households in 2008 and 7700 households in 2013 were included in the analysis. Rates of impoverishment were measured using a method proposed by the World Health Organization. Multilevel logistic modeling was used to explore the influence of the NHCR on household impoverishment. Our study found that the influence of NHCR on impoverishment varied by residential location. After the reform, in rural areas, there was a significant decline in impoverishment, although the impoverishment rate remained high. There was little change in urban areas. In addition, impoverishment in the poorest households did not decline after the NHCR. Our findings are important for policy makers in particular for evaluating reform effectiveness, informing directions for health policy improvement, and highlighting achievements in the efforts to alleviate the economic burden of households that have members with chronic diseases.
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Wang Z, Zhou X, Gao Y, Chen M, Palmer AJ, Si L. Did expansion of health insurance coverage reduce horizontal inequity in healthcare finance? A decomposition analysis for China. BMJ Open 2019; 9:e025184. [PMID: 30782750 PMCID: PMC6340012 DOI: 10.1136/bmjopen-2018-025184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES 'Horizontal inequity' in healthcare finance occurs when people with equal income contribute unequally to healthcare payments. Prior research is lacking on horizontal inequity in China. Accordingly, this study set out to examine horizontal inequity in the Chinese healthcare financing system in 2002 and 2007 through two rounds of national household health surveys. DESIGN Two rounds of cross-sectional study. SETTING Heilongjiang Province, China. PARTICIPANTS Adopting a multistage stratified random sampling, 3841 households with 11 572 individuals in 2003 and 5530 households with 15 817 individuals in 2008 were selected. METHODS The decomposition method of Aronson et al was used in the present study to measure the redistributive effects and horizontal inequity in healthcare finance. FINDINGS Over the period 2002-2007, the absolute value of horizontal inequity in total healthcare payments decreased from 93.85 percentage points to 35.50 percentage points in urban areas, and from 113.19 percentage points to 37.12 percentage points in rural areas. For public health insurance, it increased from 17.84 percentage points to 28.02 percentage points in urban areas, and decreased from 127.93 percentage points to 0.36 percentage points in rural areas. Horizontal inequity in out-of-pocket payments decreased from 79.92 percentage points to 24.83 percentage points in urban areas, and from 127.71 percentage points to 53.10 percentage points in rural areas. CONCLUSIONS Our results show that horizontal inequity in total healthcare financing decreased over the period 2002-2007 in China. In addition, out-of-pocket payments contributed most to the extent of horizontal inequity, which were reduced both in urban and rural areas over the period 2002-2007.
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Affiliation(s)
- Zhonghua Wang
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
- Creative Health Policy Research Group, Nanjing Medical University, Nanjing, China
| | - Xue Zhou
- Institute of Health Management, Mudanjiang Medical University, Mudanjiang, China
| | - Yukuan Gao
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Mingsheng Chen
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
- Creative Health Policy Research Group, Nanjing Medical University, Nanjing, China
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Centre for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Lei Si
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Shewade HD, Gupta V, Satyanarayana S, Kharate A, Sahai K, Murali L, Kamble S, Deshpande M, Kumar N, Kumar S, Pandey P, Bajpai U, Tripathy JP, Kathirvel S, Pandurangan S, Mohanty S, Ghule VH, Sagili KD, Prasad BM, Nath S, Singh P, Singh K, Singh R, Jayaraman G, Rajeswaran P, Srivastava BK, Biswas M, Mallick G, Bera OP, Jaisingh AJJ, Naqvi AJ, Verma P, Ansari MS, Mishra PC, Sumesh G, Barik S, Mathew V, Lohar MRS, Gaurkhede CS, Parate G, Bale SY, Koli I, Bharadwaj AK, Venkatraman G, Sathiyanarayanan K, Lal J, Sharma AK, Rao R, Kumar AM, Chadha SS. Active case finding among marginalised and vulnerable populations reduces catastrophic costs due to tuberculosis diagnosis. Glob Health Action 2018; 11:1494897. [PMID: 30173603 PMCID: PMC6129780 DOI: 10.1080/16549716.2018.1494897] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/25/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND There is limited evidence on whether active case finding (ACF) among marginalised and vulnerable populations mitigates the financial burden during tuberculosis (TB) diagnosis. OBJECTIVES To determine the effect of ACF among marginalised and vulnerable populations on prevalence and inequity of catastrophic costs due to TB diagnosis among TB-affected households when compared with passive case finding (PCF). METHODS In 18 randomly sampled ACF districts in India, during March 2016 to February 2017, we enrolled all new sputum-smear-positive TB patients detected through ACF and an equal number of randomly selected patients detected through PCF. Direct (medical and non-medical) and indirect costs due to TB diagnosis were collected through patient interviews at their residence. We defined costs due to TB diagnosis as 'catastrophic' if the total costs (direct and indirect) due to TB diagnosis exceeded 20% of annual pre-TB household income. We used concentration curves and indices to assess the extent of inequity. RESULTS When compared with patients detected through PCF (n = 231), ACF patients (n = 234) incurred lower median total costs (US$ 4.6 and 20.4, p < 0.001). The prevalence of catastrophic costs in ACF and PCF was 10.3 and 11.5% respectively. Adjusted analysis showed that patients detected through ACF had a 32% lower prevalence of catastrophic costs relative to PCF [adjusted prevalence ratio (95% CI): 0.68 (0.69, 0.97)]. The concentration indices (95% CI) for total costs in both ACF [-0.15 (-0.32, 0.11)] and PCF [-0.06 (-0.20, 0.08)] were not significantly different from the line of equality and each other. The concentration indices (95% CI) for catastrophic costs in both ACF [-0.60 (-0.81, -0.39)] and PCF [-0.58 (-0.78, -0.38)] were not significantly different from each other: however, both the curves had a significant distribution among the poorest quintiles. CONCLUSION ACF among marginalised and vulnerable populations reduced total costs and prevalence of catastrophic costs due to TB diagnosis, but could not address inequity.
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Affiliation(s)
- Hemant Deepak Shewade
- Department of Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Vivek Gupta
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Atul Kharate
- State TB Cell, Department of Health & Family Welfare, Government of Madhya Pradesh, Bhopal, India
| | - K.N. Sahai
- State TB Cell, Department of Health & Family Welfare, Government of Bihar, Patna, India
| | - Lakshmi Murali
- State TB Cell, Department of Health & Family Welfare, Government of Tamil Nadu, Chennai, India
| | - Sanjeev Kamble
- State TB Cell, Health Department, Government of Maharashtra, Pune, India
| | - Madhav Deshpande
- State TB Cell, Department of Health & Family Welfare, Government of Chattisgarh, Raipur, India
| | - Naresh Kumar
- State TB Cell, Department of Health & Family Welfare, Government of Punjab, Chandigarh, India
| | - Sunil Kumar
- State TB Cell, Department of Health & Family Welfare, Government of Kerala, Thiruvananthapuram, India
| | - Prabhat Pandey
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - U.N. Bajpai
- Voluntary Health Association of India (VHAI), New Delhi, India
| | - Jaya Prasad Tripathy
- Department of Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Soundappan Kathirvel
- Department of Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- Department of Community Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sripriya Pandurangan
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Subrat Mohanty
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Vaibhav Haribhau Ghule
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Karuna D. Sagili
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Banuru Muralidhara Prasad
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Sudhi Nath
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Priyanka Singh
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Kamlesh Singh
- Catholic Health Association of India (CHAI), Telangana, India
| | - Ramesh Singh
- Voluntary Health Association of India (VHAI), New Delhi, India
| | - Gurukartick Jayaraman
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - P. Rajeswaran
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | | | - Moumita Biswas
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Gayadhar Mallick
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Om Prakash Bera
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | | | - Ali Jafar Naqvi
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Prafulla Verma
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | | | - Prafulla C. Mishra
- Catholic Bishops’ Conference of India-Coalition for AIDS and Related Diseases (CBCI-CARD), New Delhi, India
| | - G. Sumesh
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - Sanjeeb Barik
- Emmanuel Hospital Association (EHA), New Delhi, India
| | - Vijesh Mathew
- Catholic Health Association of India (CHAI), Telangana, India
| | | | | | - Ganesh Parate
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | | | - Ishwar Koli
- Catholic Health Association of India (CHAI), Telangana, India
| | | | - G. Venkatraman
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - K. Sathiyanarayanan
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - Jinesh Lal
- Catholic Health Association of India (CHAI), Telangana, India
| | | | - Raghuram Rao
- Central TB Division, Revised National Tuberculosis Control Programme, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Ajay M.V. Kumar
- Department of Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Sarabjit Singh Chadha
- Department of TB and Communicable Diseases, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
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24
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Si L, Chen M, Palmer AJ. Has equity in government subsidy on healthcare improved in China? Evidence from the China's National Health Services Survey. Int J Equity Health 2017; 16:6. [PMID: 28069001 PMCID: PMC5223563 DOI: 10.1186/s12939-017-0516-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/03/2017] [Indexed: 11/10/2022] Open
Abstract
Background Monitoring the equity of government healthcare subsidies (GHS) is critical for evaluating the performance of health policy decisions. China’s low-income population encounters barriers in accessing benefits from GHS. This paper focuses on the distribution of China’s healthcare subsidies among different socio-economic populations and the factors that affect their equitable distribution. It examines the characteristics of equitable access to benefits in a province of northeastern China, comparing the equity performance between urban and rural areas. Methods Benefit incidence analysis was applied to GHS data from two rounds of China’s National Health Services Survey (2003 and 2008, N = 27,239) in Heilongjiang province, reflecting the information in 2002 and 2007 respectively. Concentration index (CI) was used to evaluate the absolute equity of GHSs in outpatient and inpatient healthcare services. A negative CI indicates disproportionate concentration of GHSs among the poor, while a positive CI indicates the GHS is pro-rich, a CI of zero indicates perfect equity. In addition, Kakwani index (KI) was used to evaluate the progressivity of GHSs. A positive KI denotes the GHS is regressive, while a negative value denotes the GHS is progressive. Results CIs for inpatient care in urban and rural residents were 0.2036 and 0.4497 respectively in 2002, and those in 2007 were 0.4433 and 0.5375. Likewise, CIs for outpatient care are positive in both regions in 2002 and 2007, indicating that both inpatient and outpatient GHSs were pro-rich in both survey periods irrespective of region. In addition, KIs for inpatient services were −0.3769 (urban) and 0.0576 (rural) in 2002 and those in 2007 were 0.0280 and 0.1868. KIs for outpatient service were -0.4278 (urban) and -0.1257 (rural) in 2002, those in 2007 were −0.2572 and −0.1501, indicating that equity was improved in GHS in outpatient care in both regions but not in inpatient services. Conclusions The benefit distribution of government healthcare subsidies has been strongly influenced by China’s health insurance schemes. Their compensation policies and benefit packages need reform to improve the benefit equity between outpatient and inpatient care both in urban and rural areas.
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Affiliation(s)
- Lei Si
- Menzies Institute for Medical Research, University of Tasmania, Medical Science 1 Building, 17 Liverpool St (Private Bag 23), Hobart, TAS, 7000, Australia.,School of Health Administration, Anhui Medical University, Meishan Road 81, Hefei, 230032, Anhui Province, People's Republic of China
| | - Mingsheng Chen
- School of Health Policy & Management, Nanjing Medical University, 211166, Nanjing, China.
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Medical Science 1 Building, 17 Liverpool St (Private Bag 23), Hobart, TAS, 7000, Australia
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